Event Feedback

Demographics

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* 1. Event Date:

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* 2. Zip Code:

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* 3. Age:

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 4. Race/Ethnicity

African American/Black

Asian

White/Caucasian

Hispanic/Latinx

Native Hawaiian/Pacific Islander

Other

Other (please specify)

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* 5. Gender

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* 6. Do you identify as a person with a disability or chronic condition?

Yes

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* 7. Number of people in your household?

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* 8. Range of annual household income:

Under $15,000

Between $15,000 and $29,999

Between $30,000 and $49,999

Between $50,000 and $74,999

Between $75,000 and $99,999

Over $100,000

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* 9. Have you served in the U.S. military?

Yes

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* 10. Are you the spouse of a veteran?

Yes

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* 11. Do you speak a language, other than English at home?

Yes

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* 12. If yes, what language are you most comfortable with?

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* 13. Empath Health Community Partnership Specialists offer free individualized informational visits, to assist you with identifying available services. Would you like to coordinate one?

Yes

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* 14. If yes, please provide your name and phone number.

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* 15. As a result of this presentation/activity, I have increased my knowledge of the services provided by Empath Health?

Yes

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* 16. I have a learned a new skill, tool, or strategy to improve my health, and to make informed healthcare decisions?

Yes

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* 17. I feel better equipped and informed to care for a loved one affected by a chronic or advanced illness, or grief?

Yes

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* 18. I was provided information on how to contact Empath Health for my healthcare needs or my loved ones?

Yes

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* 19. Please rate your satisfaction with the presentation.

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Very dissatisfied

Event Feedback

Demographics

Question Title

* 1. Event Date:

Question Title

* 2. Zip Code:

Question Title

* 3. Age:

Question Title

* 4. Race/Ethnicity

Question Title

* 5. Gender

Question Title

* 6. Do you identify as a person with a disability or chronic condition?

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* 7. Number of people in your household?

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* 8. Range of annual household income:

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* 9. Have you served in the U.S. military?

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* 10. Are you the spouse of a veteran?

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* 11. Do you speak a language, other than English at home?

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* 12. If yes, what language are you most comfortable with?

Question Title

* 13. Empath Health Community Partnership Specialists offer free individualized informational visits, to assist you with identifying available services. Would you like to coordinate one?

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* 14. If yes, please provide your name and phone number.

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* 15. As a result of this presentation/activity, I have increased my knowledge of the services provided by Empath Health?

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* 16. I have a learned a new skill, tool, or strategy to improve my health, and to make informed healthcare decisions?

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* 17. I feel better equipped and informed to care for a loved one affected by a chronic or advanced illness, or grief?

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* 18. I was provided information on how to contact Empath Health for my healthcare needs or my loved ones?

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* 19. Please rate your satisfaction with the presentation.

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* 20. Additional Comments?