US-Based Haitian Healthcare Plan

Please take a few minutes to complete this important survey about the future of Health Care in Haiti.

Health Care is such an essential part of our lives. The purpose of this survey is to get your opinions about Emergency Travel Care and Primary Care Health services in Haiti.

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* 1. Please select from the following?

Male

Female

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* 2. What is your zip code?

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* 3. Do you currently send money to your family members in Haiti?

Yes

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* 4. Which money transfer company do you most often use to send money to Haiti?

Western Union

CAM

Unitransfer

MoneyGram

Xoom

Other

I don’t send money to Haiti

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* 5. Have you traveled to Haiti in the last 3 years?

Yes

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* 6. How often do you travel back home to Haiti?

Monthly

1-3 times per year

4-6 times per year

7 or more times per year

Never

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* 7. Rate the importance of your family members receiving quality health care in Haiti?

Very Important

Somewhat important

Neutral

Not important

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* 8. Would you be interested in purchasing primary care health benefits for your family members in Haiti?

Yes, I would definitely be interested

Yes, depending on the price of the plan

Perhaps, if the quality of care was acceptable

No, I would send money and let them find their own healthcare

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* 9. Rank from 1 to 4 (lowest to highest) the primary reason you would purchase health benefits for your family members living in Haiti.

The quality of healthcare offered

The monthly price of healthcare benefits offered

Healthcare which is managed by a US based company

The types of healthcare services offered

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* 10. If while in Haiti you are involved in a health-related emergency, which of the following would you prefer?

I would select to receive emergency care in Haiti

I would request immediate evacuation to the US for care

I would receive basic necessary emergency care in Haiti then request evacuation to the US for additional care

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* 11. Which factors are important to you in selecting primary care coverage for your family members in Haiti?

Select all that apply

An easy to use sign-up process

An affordable monthly plan

A healthcare management company based in the US

A healthcare plan to provide standard of care benefits

A healthcare plan to cover me when I travel to Haiti

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* 12. Would you be interested in purchasing a health plan that offers both of the following services:

a. A service that allows you to receive emergency care benefits while in Haiti; and
b. A service that allows your family member to receive primary care in Haiti?

Yes, I would be interested

Perhaps, but only if I obtained more information on the plan

No, I am not interested

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* 13. What is the maximum monthly amount you would pay for emergency travel care for yourself and primary care for your family members?

$5-$6 per member/month

$7-$8 per member/month

$8-$9 per member/month

$9-$10 member/month

I would be interested regardless of price

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* 14. Where do you obtain your news about Haiti?

Haitian Radio

Haitian Television

Haitian Newspapers

American Media (TV, Radio, Newspaper, Websites)

Social Media (Facebook, Twitter, Instagram, Snapchat)

Word of mouth (family and/or friends)

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* 15. Please leave us your contact details to obtain additional information regarding this survey

E-mail:

Cell Phone:

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* 1. Please select from the following?

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* 2. What is your zip code?

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* 3. Do you currently send money to your family members in Haiti?

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* 4. Which money transfer company do you most often use to send money to Haiti?

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* 5. Have you traveled to Haiti in the last 3 years?

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* 6. How often do you travel back home to Haiti?

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* 7. Rate the importance of your family members receiving quality health care in Haiti?

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* 8. Would you be interested in purchasing primary care health benefits for your family members in Haiti?

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* 9. Rank from 1 to 4 (lowest to highest) the primary reason you would purchase health benefits for your family members living in Haiti.

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* 10. If while in Haiti you are involved in a health-related emergency, which of the following would you prefer?

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* 11. Which factors are important to you in selecting primary care coverage for your family members in Haiti?Select all that apply

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* 12. Would you be interested in purchasing a health plan that offers both of the following services:a. A service that allows you to receive emergency care benefits while in Haiti; and b. A service that allows your family member to receive primary care in Haiti?

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* 13. What is the maximum monthly amount you would pay for emergency travel care for yourself and primary care for your family members?

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* 14. Where do you obtain your news about Haiti?

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* 15. Please leave us your contact details to obtain additional information regarding this survey

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* 16. Please share any other comments you have below:

* 11. Which factors are important to you in selecting primary care coverage for your family members in Haiti?

Select all that apply

* 12. Would you be interested in purchasing a health plan that offers both of the following services:

a. A service that allows you to receive emergency care benefits while in Haiti; and
b. A service that allows your family member to receive primary care in Haiti?