Pilot Program Participation

Enrollment Application

The Janie Appleseed Network pilot program will engage families in the use and development of an emerging class of health information technology systems aimed at giving consumers sovereignty over their personal health data. A personal health record system, or PHR, is a digital computer application that helps a consumer store and manage personal health data captured over time. A PHR helps a person collect and use past information to inform present and future health and care choices. A subscription service for the PHR technology, called MyPHD Wellness Manager, will be provided to participating families at no charge during the pilot. The pilot program begins January 1, 2018 and runs for a full year.

Applications are being accepted in October and November, 2017. Selected participants will be notified in December, 2017.

If you are interested in having your family participate in the pilot program, please complete this survey.

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* 1. What is your age?

17 or younger

18-20

21-29

30-39

40-49

50-59

60 or older

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* 2. What is the highest level of school you have completed or the highest degree you have received?

Less than high school degree

High school degree or equivalent (e.g., GED)

Some college but no degree

Associate degree

Bachelor degree

Graduate degree

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* 3. Which of the following categories best describes your employment status?

Employed, working full-time

Employed, working part-time

Not employed, looking for work

Not employed, NOT looking for work

Retired

Disabled, not able to work

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* 4. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race?

White

Black or African-American

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific Islander

From multiple races

Some other race (please specify)

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* 5. How much total combined money did all members of your HOUSEHOLD earn last year?

$0 to $9,999

$10,000 to $24,999

$25,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000 to $124,999

$125,000 to $149,999

$150,000 to $174,999

$175,000 to $199,999

$200,000 and up

Prefer not to answer

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* 6. What is your gender?

Female

Male

Other (specify)

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* 7. Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino group?

I am not Spanish, Hispanic, or Latino

Mexican

Mexican-American

Chicano

Puerto Rican

Cuban

Cuban-American

Some other Spanish, Hispanic, or Latino group

From multiple Spanish, Hispanic, or Latino groups

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* 8. Select the program category where your family would fit best:

Family with a new baby born after January 1, 2018 and before June 30, 2018

Family caring for a child with special needs

Family caring for an elderly parent

Family with a family member with a chronic disease

Family with a family member with substance addiction challenges

Family with no major health issues and actively focused on staying healthy

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* 9. How many family members are you likely to include in the pilot program?

More than 7

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* 10. How would you rate your current computer skills?

0 Current skills are minimal

5 Average

10 Very proficient

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 11. Would you be willing to attend product training in an on-line or face-to-face session?

I would be willing to attend an on-line product training session.

I would be willing to attend a face-to-face product training session held in Washington County, RI.

I would not have time to attend a product training session.

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* 12. Would you be willing to provide product feedback?

I would be willing to attend an on-line product product feedback session once a month.

I would be willing to attend a face-to-face product feedback session once a month held in Washington County, RI.

I would be willing to answer a product feedback survey once a month, assuming it took 20 minutes or less to complete.

I would be willing to answer a product usage survey once a week, assuming it took 5 minutes or less to complete.

I would not have time to provide product feedback.

Pilot Program Participation

Enrollment Application

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* 1. What is your age?

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* 2. What is the highest level of school you have completed or the highest degree you have received?

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* 3. Which of the following categories best describes your employment status?

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* 4. Are you White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific islander, or some other race?

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* 5. How much total combined money did all members of your HOUSEHOLD earn last year?

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* 6. What is your gender?

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* 7. Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino group?

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* 8. Select the program category where your family would fit best:

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* 9. How many family members are you likely to include in the pilot program?

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* 10. How would you rate your current computer skills?

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* 11. Would you be willing to attend product training in an on-line or face-to-face session?

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* 12. Would you be willing to provide product feedback?

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* 13. Would you be willing to have a Janie Appleseed Network representative contact you to discuss the pilot program?

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* 14. What is your first name?

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* 15. What is your last name?

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* 16. At what email address would you like to be contacted?

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* 17. What is the best phone number to use to contact you?