The Conversation Project Community Activity Survey Q4 2018

Thank you for taking the time to help The Conversation Project learn about activity happening in your region to promote conversations! We are collecting this information on an on-going, quarterly basis and hope you will take a few minutes each quarter to share your progress with us! Once collected and sorted, we will share results back with you via our newsletter. We have created a template for you to collect this information on a monthly basis, if you need one. You can find it HERE.

Please answer the following about your work from October 1, 2018 to December 31, 2018

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* 1. From Oct. 1-Dec. 31, 2018: How many events/activities have you either presented at or hosted on the importance of conversations about advance care planning/end-of-life care? This includes in-person or virtual events (e.g. calls/webinars). And, this includes internal events (e.g. for your own staff) and external events (e.g. for those in your community)

# of events in October:

# of events in November:

# of events in December:

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* 2. From Oct. 1-Dec. 31, 2018: If you've hosted or presented at event(s), how many were in attendance across all events combined (roughly)? For example, if you presented at ten events in July that each had ten attendees, note 100. If you hosted 3 sessions in August with the same 10 people at each session, note 30. Your best estimate is OK; doesn't have to be exact numbers!

Total # of attendees in October:

Total # of attendees in November:

Total # of attendees in December:

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* 3. From Oct. 1-Dec. 31, 2018: If you’ve also shared specific TCP-related messages (e.g. any content, tools or resources highlighting the importance of conversations) through other mediums, please note roughly how many individuals you have reached below. Your best estimate is OK, doesn't have to be exact numbers! Please fill out only applicable fields.

#of TCP starter kits distributed that were not tied to an event:

# of individuals reached via a newsletter or email that contained TCP/conversation-related messages:

# of individuals reached via social media (e.g. if you reached 100 via a Facebook message, 100 via Facebook Live event and had 50 Twitter impressions, note 250):

# of individuals reached via other media events (e.g. if you reached 200 via podcast, had an audience of 1000 radio listeners and 1000 viewers of a TV spot, note 2200):

Additional comments on how you are reaching individuals (per above):

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* 4. Of all the resources TCP offers, which are the most valuable?
Check all that apply

Conversation Starter Kits in general

Conversation Starter Kits translations

User-submitted stories shared on TCP.org and in newsletters

Blogs shared on TCP.org and in newsletters

Community engagement resources (e.g materials on planning, hosting, facilitating events)

Health care resources

Faith resources (e.g. sermons)

Videos

General newsletter (see example)

Community engagement newsletter (see example)

Community 101 calls

Community 201 calls

Special Interest calls (Convo Sabbath, NHDD, Equity, Alzheimer’s and other topics)

Additional comments or specific details on above:

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* 5. How are you adapting our resources/tools to meet the needs of your community’s various demographics/cultures? (e.g. are you adapting messaging or terminology used for various races/ethnicities, educational levels, or abilities?)

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* 6. Is there some resource/tool you want that we aren’t yet offering? (e.g. a specific tool, call, discussion group, translated materials, etc.)

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* 7. Your Name

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* 8. Your Organization's Name and/or Your Initiative's Name

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* 9. With what type of organization are you affiliated? (Please pick the affiliation that best describes your organization.)

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* 10. E-Mail Address

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* 11. In what zipcode are you or your organization located?

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* 12. Any comments/questions (optional)

Thanks you for your participation! Please do not hesitate to contact us with any questions at conversationproject@ihi.org.

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* 4. Of all the resources TCP offers, which are the most valuable? Check all that apply

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* 5. How are you adapting our resources/tools to meet the needs of your community’s various demographics/cultures? (e.g. are you adapting messaging or terminology used for various races/ethnicities, educational levels, or abilities?)

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* 6. Is there some resource/tool you want that we aren’t yet offering? (e.g. a specific tool, call, discussion group, translated materials, etc.)

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* 7. Your Name

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* 8. Your Organization's Name and/or Your Initiative's Name

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* 9. With what type of organization are you affiliated? (Please pick the affiliation that best describes your organization.)

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* 10. E-Mail Address

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* 11. In what zipcode are you or your organization located?

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* 12. Any comments/questions (optional)

* 4. Of all the resources TCP offers, which are the most valuable?
Check all that apply