* 1. Name of event attended:

* 2. In which community was the event held?

* 3. Where did you meet the Affinity Health Plan Community Engagement Representative?

* 4. How would you rate your encounter with the Affinity Health Plan Community Engagement Representative?

* 5. When did you interact with an Affinity Health Plan Community Engagement Representative?

* 6. Were we helpful in answering your questions?

* 7. Would you keep in contact with the Affinity Health Plan Community Engagement Representative?

* 8. Tell Us, Are you......

* 9. Are you a Provider? If yes, please provide name:

* 10. How do you rate the event / presentation?

* 11. Would you attend another event presented by Affinity Health Plan?

* 12. Would you recommend the event to members of your community, family or friends?

* 13. Would you like us to bring this event into another community?

* 14. Please provide your contact information to learn more about Affinity Health Plan local events:

* 15. How Can We Improve? Give us your suggestions.

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