2018 CF Health Insurance Survey - Materials Request Form

Please use this form to request additional fliers, patient postcards, or paper surveys for your care center to promote the 2018 CF Health Insurance Survey.

If you have any questions, please contact cffcoverage@gwu.edu or 202-994-7368.

Question Title

* 1. Care Center

Care Center Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Center Contact Name

Email Address

Phone Number

Question Title

* 2. Care Center Type

Adult

Pediatric

Affiliate

Question Title

* 3. Number of clinic fliers
Clinic fliers are intended to be posted on bulletin boards, doors, or other public spaces to promote the survey.

Question Title

* 4. Number of patient postcards
Patient postcards are intended for distribution to patients and family members to promote the survey.

Question Title

* 5. Number of paper surveys
We are encouraging survey respondents to use a computer or smartphone to complete the survey electronically. However, we do have paper surveys available if you feel that your patients will be more likely to complete them. Paper surveys will be mailed to your center in pre-stamped/pre-addressed envelopes.

Person with CF

Parent or guardian of someone with CF

Spouse or partner or someone with CF

Caregiver of someone with CF

Question Title

* 1. Care Center

Question Title

* 2. Care Center Type

Question Title

* 3. Number of clinic fliersClinic fliers are intended to be posted on bulletin boards, doors, or other public spaces to promote the survey.

Question Title

* 4. Number of patient postcardsPatient postcards are intended for distribution to patients and family members to promote the survey.

Question Title

* 3. Number of clinic fliers
Clinic fliers are intended to be posted on bulletin boards, doors, or other public spaces to promote the survey.

* 4. Number of patient postcards
Patient postcards are intended for distribution to patients and family members to promote the survey.