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* 1. Did you know that there are insurance counselors available in your area to explain Medicare and Medicaid?

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* 2. If yes, how did you learn about the SHIP program?

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* 3. What is your county of residence?

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* 4. What is your age?

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* 5. Is your monthly income below $1,405 (single) or $1,902 (married)

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* 6. If yes, were you aware that you could be eligible for assistance paying for your prescription drugs and insurance costs?

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* 7. Would you like someone to contact you regarding assistance in paying for prescription drug and insurance costs?

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* 8. What type of insurance do you have?

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* 9. Do you understand your insurance benefits, coverage and fees?

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* 10. If you had a question regarding your insurance, claims or bills, do you know who to contact for assistance?

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* 11. Have you spoken with someone regarding your Medicare or Medicaid insurance this year?

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* 12. If yes, which agency provided you with the information you requested?

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* 13. What is the name of the SHIP counselor who assisted you?

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* 14. Please rate the following:

  Strongly agree Agree Disagree Strongly disagree
The SHIP counselor was polite and helpful
The SHIP counselor provided useful and appropriate information to me
I understand the information the SHIP counselor provided
The information was provided in a timely manner
The SHIP counselor provided me with enough information to make my own informed decisions
Based on my experience, I would refer others to the SHIP counselor who assisted me
Based on my experience, I would use the SHIP counselor services in the future
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