TCP Survey Event Follow-up Template

Thank you for attending a Conversation Project event; we hope you found the information helpful. We also thank you for taking a moment to respond to a few questions. Your responses will be kept anonymous and help us learn more about the impact of our events and how to best support members of your community. If you have comments or questions for us, please respond to question 8.

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* 1. About my own wishes:

I am not interested in speaking with a loved one about my wishes for care at the end of life. (If this is true, skip to question 3).

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* 2. About my own wishes (please select all that apply)

	Yes, I had already done this.	Yes, this was prompted by the Conversation Project event.	No.
Get Ready: I have decided to have a conversation about my own wishes for care at the end of life.	Get Ready: I have decided to have a conversation about my own wishes for care at the end of life. Yes, I had already done this.	Get Ready: I have decided to have a conversation about my own wishes for care at the end of life. Yes, this was prompted by the Conversation Project event.	Get Ready: I have decided to have a conversation about my own wishes for care at the end of life. No.
Get Set: I have completed the Conversation Starter Kit.	Get Set: I have completed the Conversation Starter Kit. Yes, I had already done this.	Get Set: I have completed the Conversation Starter Kit. Yes, this was prompted by the Conversation Project event.	Get Set: I have completed the Conversation Starter Kit. No.
Get Set: I have set up a time to talk with a loved one about my own wishes.	Get Set: I have set up a time to talk with a loved one about my own wishes. Yes, I had already done this.	Get Set: I have set up a time to talk with a loved one about my own wishes. Yes, this was prompted by the Conversation Project event.	Get Set: I have set up a time to talk with a loved one about my own wishes. No.
Go: I have shared my preferences for end-of-life care with someone close to me so he/she now knows more about what is important to me.	Go: I have shared my preferences for end-of-life care with someone close to me so he/she now knows more about what is important to me. Yes, I had already done this.	Go: I have shared my preferences for end-of-life care with someone close to me so he/she now knows more about what is important to me. Yes, this was prompted by the Conversation Project event.	Go: I have shared my preferences for end-of-life care with someone close to me so he/she now knows more about what is important to me. No.
Keep Going: I have discussed my health care preferences with my doctor.	Keep Going: I have discussed my health care preferences with my doctor. Yes, I had already done this.	Keep Going: I have discussed my health care preferences with my doctor. Yes, this was prompted by the Conversation Project event.	Keep Going: I have discussed my health care preferences with my doctor. No.
Keep Going: I have appointed a health care decision-maker (agent/proxy).	Keep Going: I have appointed a health care decision-maker (agent/proxy). Yes, I had already done this.	Keep Going: I have appointed a health care decision-maker (agent/proxy). Yes, this was prompted by the Conversation Project event.	Keep Going: I have appointed a health care decision-maker (agent/proxy). No.

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* 3. About a loved one's wishes:

I am not interested in speaking with a loved one about their wishes for care at the end of life. (If this is true, skip to question 5).

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* 4. About a loved one's wishes (please select all that apply)

	Yes, I had already done this.	Yes, this was prompted by The Conversation Project event.	No.
Get Ready: I have decided to have a conversation with a loved one about his/her wishes for care at the end of his/her life.	Get Ready: I have decided to have a conversation with a loved one about his/her wishes for care at the end of his/her life. Yes, I had already done this.	Get Ready: I have decided to have a conversation with a loved one about his/her wishes for care at the end of his/her life. Yes, this was prompted by The Conversation Project event.	Get Ready: I have decided to have a conversation with a loved one about his/her wishes for care at the end of his/her life. No.
Get Set: I have shared the Conversation Starter Kit with a loved one.	Get Set: I have shared the Conversation Starter Kit with a loved one. Yes, I had already done this.	Get Set: I have shared the Conversation Starter Kit with a loved one. Yes, this was prompted by The Conversation Project event.	Get Set: I have shared the Conversation Starter Kit with a loved one. No.
Get Set: I have set up a time to talk about his or her wishes.	Get Set: I have set up a time to talk about his or her wishes. Yes, I had already done this.	Get Set: I have set up a time to talk about his or her wishes. Yes, this was prompted by The Conversation Project event.	Get Set: I have set up a time to talk about his or her wishes. No.
Go: A loved one shared his/her preferences for end-of-life care with me so I now know more about what is important to him/her.	Go: A loved one shared his/her preferences for end-of-life care with me so I now know more about what is important to him/her. Yes, I had already done this.	Go: A loved one shared his/her preferences for end-of-life care with me so I now know more about what is important to him/her. Yes, this was prompted by The Conversation Project event.	Go: A loved one shared his/her preferences for end-of-life care with me so I now know more about what is important to him/her. No.
Keep Going: My loved one has discussed his/her health care preferences with his/her doctor.	Keep Going: My loved one has discussed his/her health care preferences with his/her doctor. Yes, I had already done this.	Keep Going: My loved one has discussed his/her health care preferences with his/her doctor. Yes, this was prompted by The Conversation Project event.	Keep Going: My loved one has discussed his/her health care preferences with his/her doctor. No.
Keep Going: My loved one has appointed a health care decision-maker (agent/proxy).	Keep Going: My loved one has appointed a health care decision-maker (agent/proxy). Yes, I had already done this.	Keep Going: My loved one has appointed a health care decision-maker (agent/proxy). Yes, this was prompted by The Conversation Project event.	Keep Going: My loved one has appointed a health care decision-maker (agent/proxy). No.

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* 5. My age is (optional):

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* 6. I identify as (optional):

Female

Male

Other

Prefer not to answer

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* 7. My race/ethnicity is (optional, select all that apply):

American Indian or Alaska Native

Asian, Asian-American

Black, African American

Hispanic, Latino, or Spanish origin

Native Hawaiian or Other Pacific Islander

White

Other race

Do not know

Prefer not to answer

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* 8. Any other questions or suggestions for us? For example, if you are not yet ready to have The Conversation, what's keeping you from taking the next step? Is there anything we could have done or included in our event to help you feel better prepared? (optional)