APPENDIX: Survey Tool

APPENDIX: Survey Tool

Please answer each question as accurately as you can.

1. Would you like to use email to communicate with your doctor or nurse? a) Yes b) No

2. Do you have your own email account? a) Yes b) No

3. How often do use email (either your own account or someone else’s)?

a) Never b) monthly or less c) every 2-3 weeks d) weekly e) a few times per week f) daily or more

If never, please skip to question 8

4. How often do you use email with your medical doctors, nurses, or clinic staff?

a) Never b) monthly or less c) every 2-3 weeks d) weekly e) a few times per week f) daily or more

5. Where do you normally go to use email?

a) home b) library c) friend or relative’s house d) school e)other ______(please describe)

6. If you use email somewhere other than your home, how long does it usually take to get there from your home? a)less than 10 min b)10-30min c)30-60min d) over 60min e) I use email at home

7. Does a friend or family member usually help you use email? a) Yes b) No

8. If you normally do not use email, how difficult would it be to find a friend or family member to help you email your doctor or nurse? a)very difficult b)somewhat difficult c) neutral d) somewhat easy

e) very easy f) Does not apply, I normally use email or would not need help

9. If you could use email to communicate with your doctor, how often would you do this?

a)never b)monthly or less c)every 2-3 weeks d)weekly e)few times per week f)daily or more

10. How often do you use the internet to get information on health?

a)never b)monthly or less c)every 2-3 weeks d)weekly e)few times per week f)daily or more

11. How often do you send and receive text messages using a phone?

a)never b)monthly or less c)every 2-3 weeks d)weekly e)few times per week f)daily or more

12. Would you like to receive phone text messages to remind you of clinic appointments? a)Yes b)No

13. How difficult is it for you to type a message on a computer keyboard?

a) Very difficult b)Somewhat difficult c)Neutral d) Somewhat easy e)Very easy

14. If you could send email, how long should it take a doctor to get back to you after you send a

non-urgent email? a) 24 hours or less b) 1-2 days c) at most 72 hours d) at most one week e)other______

Please respond to the following statements and questions about Email by circling one of six answers from “strongly disagree” to “strongly agree” or “not sure”

15. Email could improve communication between patients here and their doctors or nurses.