| Model Instance Name: |
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red & strike-through: DELETE |
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| #REF! |
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underlined & italicized: RE-ORDER |
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| MID: Existing Measure - Please fill in; New Measure - DOT will fill in |
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pink: ADDITION |
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| Date: |
6/25/2009 |
blue + -->: REWORDING |
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| #REF! |
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QID
(Group ID) |
Skip Logic Label |
Question Text |
Answer Choices
(limited to 50 characters) |
Skip to |
Type (select from list) |
Single or Multi |
Required
Y/N |
Special Instructions |
25 character limit. Leave blank if you want DOT to fill this part out.
CQ Label |
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What best describes your role when coming to this site? |
Individual |
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Radio button, one-up vertical |
Single |
Y |
OPS Group |
Role |
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Business Owner |
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Emergency Personnel |
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Student/Educator |
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Other (please specify) |
A |
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A |
Other Role |
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Text field, <100 char |
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N |
OPS Group |
Other Role |
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What were you primarily looking for on DisasterAssistance.gov today? |
To apply for assistance |
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Radio button, one-up vertical |
Single |
Y |
OPS Group |
Looking for |
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Check the status of your application |
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Find information about disaster assistance resources |
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Other (please specify) |
D |
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D |
Please specify what you were looking for. |
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Text field, <100 char |
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N |
OPS Group |
Other looking for |
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What type of assistance information were you looking for today? (Check all that apply) |
Employment |
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Checkbox, one-up vertical |
Multi |
Y |
OPS Group |
Type of Assistance |
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Home Repairs |
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Personal Property Damages |
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Disaster Unemployment |
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Crisis Counseling |
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Food |
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Housing |
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Legal |
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Medical |
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None |
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Other (please specify) |
F |
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F |
Other Assistance Information |
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Text field, <100 char |
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N |
OPS Group |
Other Assistance |
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Did you take the Pre-Screening Questionnaire? |
Yes |
X |
Radio button, one-up vertical |
Single |
Y |
Skip Logic Group |
Use PreScreen |
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No |
Y |
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Don't Know |
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X |
Did the questionnaire help you find what you needed? |
Yes |
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Radio button, one-up vertical |
Single |
Y |
Skip Logic Group |
Did PreScreen Help |
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No |
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Y |
Why did you not use the Pre-Screen Questionnaire? |
I did not see the questionnaire link |
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Radio button, one-up vertical |
Single |
Y |
Skip Logic Group |
No PreScreen |
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I already knew what forms of assistance I needed |
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I did not need to find any disaster forms of assistance |
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I started to take it but did not understand the questions |
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I started to take it but did not understand the selection options |
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I didn't have time |
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Other (please specify) |
M |
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M |
Other reason you did not use the Pre-Screen Questionnaire. |
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Text field, <100 char |
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N |
Skip Logic Group |
Other No PreScreen |