ACP -- Just Talk About It
Exit this survey >>
1. Default Section
1
. Did you watch all three videos on Advance Care Planning?
Did you watch all three videos on Advance Care Planning?
yes
no
2
. If no, which one(s) did you watch?
If no, which one(s) did you watch?
A Family Way (a middle aged couple and their adult daughter)
A Friend in Need (two women at a doctor's office)
Where There's a Will (two men in wheelchairs at the gym)
3
. On a scale of 1 - 7, how helpful were these videos to "just talk about" advance care planning?
not helpful
very helpful
How helpful?
*
On a scale of 1 - 7, how helpful were these videos to "just talk about" advance care planning? How helpful? not helpful
How helpful?
How helpful?
How helpful?
How helpful?
How helpful?
How helpful? very helpful
4
. Have you decided who should be your health care agent, that is, who should speak for you if you cannot speak for yourself?
Have you decided who should be your health care agent, that is, who should speak for you if you cannot speak for yourself?
yes
no
5
. If yes, have you discussed your wishes and values with that person?
If yes, have you discussed your wishes and values with that person?
yes
no
6
. Have you put your choice of health care agent in writing?
Have you put your choice of health care agent in writing?
yes
no
7
. If you have not yet chosen a health care agent, have these videos helped you decide to take action?
never
someday
soon
as soon as possible
After seeing these videos, I plan to choose a health care agent
*
If you have not yet chosen a health care agent, have these videos helped you decide to take action? After seeing these videos, I plan to choose a health care agent never
After seeing these videos, I plan to choose a health care agent someday
After seeing these videos, I plan to choose a health care agent soon
After seeing these videos, I plan to choose a health care agent as soon as possible
8
. What messages about advance care planning were most important to you?
What messages about advance care planning were most important to you?
9
. What new information did you learn about Advance Care Planning, if any?
What new information did you learn about Advance Care Planning, if any?
10
. What more would you like to learn about advance care planning? We welcome any comments or concerns that can help us to create more public service videos. Thanks for your help!
What more would you like to learn about advance care planning? We welcome any comments or concerns that can help us to create more public service videos. Thanks for your help!
Powered by
SurveyMonkey
Create your own
free online survey
now!
Javascript is required for this site to function, please enable.