The Conversation Project Community Activity Survey Q1 2018

Thank you for taking the time to help The Conversation Project learn about activity happening across the country to promote conversations! We plan to collect 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. If you are interested in testing out a template we have created to collect this information on a monthly basis, please let us know and we will share it with you.

Please answer the following about your work from January 1, 2018 to March 31, 2018

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* 1. From January 1-March 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 January:

# of events in February:

# of events in March:

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* 2. From January 1-March 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 Janurary that each had ten attendees, note 100. If you hosted 3 sessions in March 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 January:

Total # of attendees in February:

Total # of attendees in March:

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* 3. Who are you reaching? Please characterize the types of audiences attending events or being reached through other activities. Are there any particular demographics - by age, gender, race, income, religion - you are focusing on?

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* 4. If you are working with partners, how many are you working with (roughly) and what types of partners? For example: 6 partners - local hospital, meals on wheels, county public health department, estate planners, State Hospital Association, local church.

# of partners:

Type of partners:

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* 5. From January 1-March 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 that contained TCP/conversation-related messages:

# of individuals reached via social media (e.g if you reached 100 via a Facebook message and had 50 Twitter impressions, note 150):

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

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* 6. Please share any key feedback from attendees who have participated in any of your conversation-related events (positive or constructive). In particular, we'd like to hear any feedback on the influence and impact these events/this work is making or any feedback you are hearing from individuals on challenges they still face with initiating conversations with loved ones. (optional)

Influence and impact of these events/this work:

Challenges individuals have shared with initiating conversations:

Other:

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* 7. Your Name

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* 8. Your Organization's Name (write N/A if not affiliated with an organization)

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* 9. With what type of organization are you affiliated?

Individual, no affiliated organization

Aging/Senior Services

Assisted Living/Senior Housing Facility

Business/Local Employer

Estate/Legal/Financial Entity

Faith-Based Organization

Foundation

Health Care (Home Care/Hospice/Hospital/Healthcare System/Nursing home etc.)

Town/City/State Community Organization

Other (please specify)

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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.