Just Congregations Health Care Survey

Temple Emanu-El’s Just Congregations Core Team is involved in a process to identify the health care concerns of our members. To help better understand the situation in our congregation, we are asking you to take a few minutes to answer the following questions:

All responses will be kept confidential.

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* 1. Please indicate your current health insurance coverage for yourself and for other members of your household.

	Yourself	Other Household Members
Insurance obtained through an employer (your employer or someone else’s in the household)	Insurance obtained through an employer (your employer or someone else’s in the household) Yourself	Insurance obtained through an employer (your employer or someone else’s in the household) Other Household Members
Insurance that you purchase individually for yourself	Insurance that you purchase individually for yourself Yourself	Insurance that you purchase individually for yourself Other Household Members
Medicare (including supplemental and prescription coverage)	Medicare (including supplemental and prescription coverage) Yourself	Medicare (including supplemental and prescription coverage) Other Household Members
Medicaid	Medicaid Yourself	Medicaid Other Household Members
CHIP	CHIP Yourself	CHIP Other Household Members
Other (Please specify Below)	Other (Please specify Below) Yourself	Other (Please specify Below) Other Household Members
No health insurance	No health insurance Yourself	No health insurance Other Household Members

Other (please specify)

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* 2. Which of the following group approximates the monthly health insurance costs for yourself and other household members?

Less than $200 per month

$200 to $499 per month

$500 or more per month

Don’t know or no answer

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* 3. How many household members are covered by this monthly cost?

Number of people covered

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* 4. Which of the following costs is currently a major concern to your household?
A. First, please check all that apply
B. Second, check the cost that is the greatest concern to your household.
C. Third, check the cost that is the next greatest concern to your household.

	Check All That Apply	Greatest Concern ........(only one)	Next Greatest Concern ...(only one)
The cost of the health insurance premium	The cost of the health insurance premium Check All That Apply	The cost of the health insurance premium Greatest Concern ........(only one)	The cost of the health insurance premium Next Greatest Concern ...(only one)
The cost of prescription medicines	The cost of prescription medicines Check All That Apply	The cost of prescription medicines Greatest Concern ........(only one)	The cost of prescription medicines Next Greatest Concern ...(only one)
The cost of dental insurance	The cost of dental insurance Check All That Apply	The cost of dental insurance Greatest Concern ........(only one)	The cost of dental insurance Next Greatest Concern ...(only one)
The cost of long-term care	The cost of long-term care Check All That Apply	The cost of long-term care Greatest Concern ........(only one)	The cost of long-term care Next Greatest Concern ...(only one)
The cost for providing end-of-life care	The cost for providing end-of-life care Check All That Apply	The cost for providing end-of-life care Greatest Concern ........(only one)	The cost for providing end-of-life care Next Greatest Concern ...(only one)
The cost of medical equipment or supplies	The cost of medical equipment or supplies Check All That Apply	The cost of medical equipment or supplies Greatest Concern ........(only one)	The cost of medical equipment or supplies Next Greatest Concern ...(only one)
Other costs (Please specify below)	Other costs (Please specify below) Check All That Apply	Other costs (Please specify below) Greatest Concern ........(only one)	Other costs (Please specify below) Next Greatest Concern ...(only one)
None of these costs are currently a major concern to my household	None of these costs are currently a major concern to my household Check All That Apply	None of these costs are currently a major concern to my household Greatest Concern ........(only one)	None of these costs are currently a major concern to my household Next Greatest Concern ...(only one)

Other Costs (please specify)

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* 5. During the past 12 months, have you or any member of your household been hospitalized or had significant medical care for any reason?

	Yourself	Other Household Members
Yes, have been hospitalized or had significant medical care	Yes, have been hospitalized or had significant medical care Yourself	Yes, have been hospitalized or had significant medical care Other Household Members
No	No Yourself	No Other Household Members
Don't know or no answer	Don't know or no answer Yourself	Don't know or no answer Other Household Members

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* 6. (IF YES ABOVE): How satisfied were you or other household members with the insurance coverage?

	Yourself	Other Household Members
Very satisfied	Very satisfied Yourself	Very satisfied Other Household Members
Somewhat satisfied	Somewhat satisfied Yourself	Somewhat satisfied Other Household Members
Somewhat dissatisfied	Somewhat dissatisfied Yourself	Somewhat dissatisfied Other Household Members
Very dissatisfied	Very dissatisfied Yourself	Very dissatisfied Other Household Members
Don't know or no answer	Don't know or no answer Yourself	Don't know or no answer Other Household Members

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* 7. What pressures are you or other household members feeling about issues of health care?

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* 8. How many people reside in your household in each of these age groups?

Under 18

18 to 34 years old

35 to 49 years old

50 to 64 years old

65 years old

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* 9. Over the next few months, Temple Emanu-El’s Just Congregations Core Team will be speaking with congregants about health care as a part of a congregational listening campaign. We want you to get involved. Please provide your contact information below and a member of our Just Congregations Core-Team will follow-up with you.

Name

Phone Number

If you do not want to provide your name here because you are concerned about the confidentiality of your responses, but you would like to get involved in the listening campaign, please contact Penny Coney at coneyL@cfbisd.edu or 972-971-3360.

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* 1. Please indicate your current health insurance coverage for yourself and for other members of your household.

Question Title

* 2. Which of the following group approximates the monthly health insurance costs for yourself and other household members?

Question Title

* 3. How many household members are covered by this monthly cost?

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* 4. Which of the following costs is currently a major concern to your household?A. First, please check all that applyB. Second, check the cost that is the greatest concern to your household.C. Third, check the cost that is the next greatest concern to your household.

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* 5. During the past 12 months, have you or any member of your household been hospitalized or had significant medical care for any reason?

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* 6. (IF YES ABOVE): How satisfied were you or other household members with the insurance coverage?

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* 7. What pressures are you or other household members feeling about issues of health care?

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* 8. How many people reside in your household in each of these age groups?

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* 4. Which of the following costs is currently a major concern to your household?
A. First, please check all that apply
B. Second, check the cost that is the greatest concern to your household.
C. Third, check the cost that is the next greatest concern to your household.