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* 1. SHIP counseling is the provision of information and assistance to Medicare beneficiaries and older
individuals 60 and over concerning health insurance benefits, prescription drug assistance and other
insurance benefits.Which agency provides your SHIP counseling?

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* 2. Age

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* 3. Gender

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* 4. Assistance requested by....

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* 5. How did you learn about SHIP?

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* 6. Name of the SHIP Counselor who assisted you...

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* 7. Were you able to receive assistance at the time of your call or did you leave a message?

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* 8. If you had to leave a message, when was the call returned?

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* 9. Please rate the following....

  Strongly agree Agree Disagree Strongly disagree
Your SHIP counselor was polite and helpful.
The SHIP counselor provided useful and appropriate information for me.
I understood the information the SHIP counselor provided.
The information I needed was provided in a timely manner.
The SHIP counselor provided me with enough information to make my own informed
decision.

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* 10. Based on your experience, would you refer others to SHIP counseling or use the services again yourself?

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* 11. Additional Comments

T