Medicare Group Education Satisfaction Survey

Page 1 - Background

You have been directed to this survey because you recently attended a presentation about Medicare. This survey has three pages and should take less than five minutes to complete. Your responses are completely anonymous and will help our programs improve their services to individuals like yourself. This survey was approved by the United States Government's Office of Management and Budget, Control Number 0985-0056.

If you have any questions about this survey please contact katherine.glendening@acl.hhs.gov.

Question Title

* 1. Please enter the date when you attended a group outreach and education presentation.

Date / Time

Date

Time

AM/PM

Question Title

* 2. Please select the State or Territory that organized the presentation.

Question Title

* 3. Which organization was responsible for the presentation?

SHIP (State Health Insurance Assistance Program)

SMP (Senior Medicare Patrols)

Other (please specify)

Question Title

* 4. Please enter the name of the presenter. If you do not remember his/her name, please enter N/A and proceed to Question 5.

Question Title

* 5. How did you learn about today's presentation?

Event location announcement (e.g., senior center, library)

Mailing

Friend or relative

Another agency

Website

Previous presentation

TV, radio, or newspaper

Flyer

Other (please specify)