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Georgia Voices for Medicaid Consumer Satisfaction Survey Pre-Test (12/15)

Preliminary questions for Georgia Voices for Medicaid Consumer Satisfaction Survey

Your contact information will only be shared with GHF so that we can follow up with you after the presentation. Your contact information and individual responses will not be shared with any other organization or individual.

1.Date

Date / Time

Date

1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916

SuSunday

MoMonday

TuTuesday

WeWednesday

ThThursday

FrFriday

SaSaturday

2.Where in Georgia are you located?

3.Please enter your name.

4.Please enter your email.

5.Check all the boxes below that describe you.

I am a self-advocate (the practice of developmentally disabled people speaking up for themselves and controlling their own affairs.)

I am a family member of a self-advocate.

I am a professional or other.

I live in Rural Georgia (outside of a city of Georgia.)

I am a man.

I am a woman.

My gender is non-binary.

I prefer not to tell you my gender.

I am white.

I am Native Hawaiian or other Pacific Islander.

I am Asian.

I am Native American/American Indian.

I am Hispanic/Latino.

I am two or more races.

I am Black or African American.

I don't know my race/I choose not to tell you what my race is.

6.I am interested in learning more about the Georgia Health Action Network.

Yes

No

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