An example of a custom survey I created for a previous employer in the healthcare industry. The goal was to understand how product use was impacted by social variables of the work environment.

1. Amerigroup User Survey Questions
Based upon the major tasks users can accomplish within ProviderPortal, the following survey questions
have been developed as the first step in conducting the AGP research. The questions on each page touch
on some key attributes of the user experience that need to be understood in order to assess the type
and extent of damage done by the data issue in ProviderPortal, and design an effective solution that
addresses that damage.
DIRECTIONS <PAGE 1>
Please indicate how confident you are that you can accomplish the key tasks in ProviderPortal using the
scale below. If you do not perform an activity, please select the option labeled ‘N/A’ in the far right
column.
1 = not at all confident, 7 = extremely confident.
1. Log into ProviderPortal.
2. Search for a member in ProviderPortal.
3. Search for an ordering provider in ProviderPortal.
4. Start an order request.
5. Find an exact exam requested by an ordering provider.
6. Find the symptom related to a requested exam.
7. Provide additional clinical information for a requested exam.
8. Submit an order.
9. Search for a servicing provider in ProviderPortal.
10. Check the status of existing orders.
11. Update profile information.
12. Update provider information.
DIRECTIONS <PAGE 2>
Please indicate your agreement with each of the statements below as they relate to ProviderPortal.
1 = strongly disagree, 7 = strongly agree.
1. I intend to use ProviderPortal in the future.
2. I do not want to use ProviderPortal in the future.
3. Using ProviderPortal is a good idea.
4. Using ProviderPortal is better than calling the call center.
5. I dislike using ProviderPortal.
6. There is a possibility that ProviderPortal might malfunction.
7. There is a possibility that I cannot complete order requests through ProviderPortal.
8. Using ProviderPortal helps me work more effectively
9. Using ProviderPortal helps me work more quickly.

2. 10. Using ProviderPortal helps me work more efficiently.
11. I do not think ProviderPortal is useful.
12. My coworkers think using ProviderPortal is a good idea.
13. My doctors think using ProviderPortal is a good idea.
14. I can easily get help from AIM Specialty Health whenever I have trouble using ProviderPortal.
a. Follow up question: How do you typically receive help with ProviderPortal?
i. Via telephone
ii. Via the web
DIRECTIONS <PAGE 3>
Thank you for completing this survey. Based on your responses, AIM Specialty Health would like to talk
to you more about your experiences using ProviderPortal. If you would like someone from AIM
Speciality Health to contact you about participating in a 15-minute phone interview, please provide your
contact information below.
<NAME>
<WORK EMAIL>
<WORK TELEPHONE NUMBER>
Understanding the Survey Questions
For this portion of the research, several variables are of interest:
● Self-efficacy​- confidence that one can accomplish that basic tasks associated with using
ProviderPortal.
o Measured by the 12 items indicated as belonging on page 1.
● Behavioral intent​- the decision one makes regarding the use of ProviderPortal.
o Measured by the following survey items:
▪ I intend to use ProviderPortal in the future.
▪ I do not want to use ProviderPortal in the future.
● Attitude​- what one thinks and feels about ProviderPortal.
o Measured by 3 survey items:
▪ Using ProviderPortal is a good idea.
▪ Using ProviderPortal is better than calling the call center.
▪ I dislike using ProviderPortal.
● Perceived Risk​- how safe users think it is to use ProviderPortal.
o Three survey items relate to this variable:
▪ There is a possibility that ProviderPortal might malfunction.
▪ There is a possibility that I cannot complete order requests through
ProviderPortal.
▪ I can easily get help from AIM Specialty Health whenever I have trouble using
ProviderPortal.

3. ● Perceived usefulness​- whether users think the tool is useful for their work.
o Four items measure this variable:
▪ Using ProviderPortal helps me work more effectively
▪ Using ProviderPortal helps me work more quickly.
▪ Using ProviderPortal helps me work more efficiently.
▪ I do not think ProviderPortal is useful.
● Acceptance of interface (a.k.a., use norms)​- how accepted ProviderPortal is within the work
environment.
o Measured by two items:
▪ My coworkers think using ProviderPortal is a good idea.
▪ My doctors think using ProviderPortal is a good idea.
The above variables are included in the survey due to the amount of research indicating that the work
environment, attitudes, and perceptions of products can impact whether a product is used, and how it is
used. As the creators of ProviderPortal, AIM can address the attitudes and perceptions of Amerigroup
users, but only once they are understood. AIM can also address any negative issues regarding
self-efficacy through online help (such as PDF guides or tutorials) and the call center (via outreach, or
when users call) once their extent is understood.
Using the Survey Results
The survey responses will undergo a statistical analysis to gauge levels of the variables of interest among
the Amerigroup users. That data will then be used to guide individual interviews with volunteers from
the original group of survey respondents. These interviews will cover the following topics:
● What does ProviderPortal do well?
● Which activities on ProviderPortal do you find you need help with?
● What can AIM do to make ProviderPortal more useful for you?
● What are some of the competitor portals you use?
● How does AIM compare to the other portals you use?
Version Changes
1/9/2015- Updated with suggestions from Lori by Leslie M.
1/13/2015- Survey ready to be launched. Waiting for the 2014 CXG Welcome Survey to close before
sending this one to AGP users.
● There are 503 CXG opt-ins that identify as Amerigroup plan servicers.
● Survey will be piloted with 100 randomly selected new Amerigroup opt-ins.