Assessing Your Readiness for Healthy Change Evaluation Survey

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* 1. Are you a TRICARE West beneficiary?
(If your health coverage is TRICARE and you live in one of these states you may be a TRICARE West beneficiary: AZ, CA, CO, ID, IA, KS, MN, MO, MT, NE, NV, NM, ND, OR, SD, WA, WY, El Paso, TX)

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* 2. What behavior change are you wanting to make?

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* 3. Did completing this program help you determine your readiness for making your behavior change?

Yes

Somewhat

No (If no, please explain below)

Please explain:

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* 4. How long did it take you to complete this program?

Completed it in one day

Completed it in two days or more

Other (Please specify):

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* 5. How much do you agree with the following statements about this program?

	Strongly Agree	Agree	Somewhat Agree	Disagree	Strongly Disagree	No Opinion
The format was an effective way to present the topic	The format was an effective way to present the topic Strongly Agree	The format was an effective way to present the topic Agree	The format was an effective way to present the topic Somewhat Agree	The format was an effective way to present the topic Disagree	The format was an effective way to present the topic Strongly Disagree	The format was an effective way to present the topic No Opinion
It was easy to move through	It was easy to move through Strongly Agree	It was easy to move through Agree	It was easy to move through Somewhat Agree	It was easy to move through Disagree	It was easy to move through Strongly Disagree	It was easy to move through No Opinion
It was clear and organized	It was clear and organized Strongly Agree	It was clear and organized Agree	It was clear and organized Somewhat Agree	It was clear and organized Disagree	It was clear and organized Strongly Disagree	It was clear and organized No Opinion
The content was easy to understand	The content was easy to understand Strongly Agree	The content was easy to understand Agree	The content was easy to understand Somewhat Agree	The content was easy to understand Disagree	The content was easy to understand Strongly Disagree	The content was easy to understand No Opinion
The tools and resources were helpful	The tools and resources were helpful Strongly Agree	The tools and resources were helpful Agree	The tools and resources were helpful Somewhat Agree	The tools and resources were helpful Disagree	The tools and resources were helpful Strongly Disagree	The tools and resources were helpful No Opinion
I gained helpful information and skills	I gained helpful information and skills Strongly Agree	I gained helpful information and skills Agree	I gained helpful information and skills Somewhat Agree	I gained helpful information and skills Disagree	I gained helpful information and skills Strongly Disagree	I gained helpful information and skills No Opinion
I would recommend this program to others	I would recommend this program to others Strongly Agree	I would recommend this program to others Agree	I would recommend this program to others Somewhat Agree	I would recommend this program to others Disagree	I would recommend this program to others Strongly Disagree	I would recommend this program to others No Opinion

If you did not agree with any of the above statements please explain why:

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* 6. Which sections of this program did you find most helpful? (Choose all that apply)

Readiness for Change (determing your readiness to make a healthy change)

Setting the Stage for Success (includes SMART goals and identifying obstacles and solutions)

Skills for Success (motivation, dealing with setbacks, celebrating success)

Program Resources

None of the above

Please explain:

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* 7. Which of the following concepts or tools did you or do you plan to use to help you make your change? (Choose all that apply)

Importance and confidence ratings

Cost-benefit chart

Preparing for change

Setting and tracking SMART goals

Identifying obstacles and solutions

Staying motivated suggestions

Celebrating my successes

Other (Please explain):

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* 8. Now that you have completed this program, what actions do you plan to take toward your health goals? (Choose all that apply)

Complete forms in the Program Resources section

Schedule activities on my calendar

Join a group or get a support partner

Take an online program or teleclass relating to the health change I want to make

Write out a plan to help me succeed

Other (Please specify):

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* 9. This program would be better if:

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* 10. Overall, how would you rate this program?

Excellent

Good

Fair

Poor

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* 11. Please use the space below to provide additional comments about the program:

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* 12. Gender

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* 13. Age (Number format, for example, 45)

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* 14. Branch of service of the Tricare sponsor

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* 15. Duty status

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* 16. Do you receive your health care at a military hospital or clinic?

Yes

If yes, which facility?

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* 17. How did you learn about this online program?

Family, friend or co-worker

Health Net Federal Services employee

Health Net Federal Services, Health and Wellness Programs email

Health Risk Assessment

Military facility, hospital or clinic

Self-referred

Social media

Telephone voice message

TRICARE newsletter (electronic or print)

Other (please specify):

Thank you for your time. We value your input and strive to create programs specific to your needs. When you click the Done button you will be routed to the program resources and handouts. We wish you much success in reaching your healthy lifestyle goals.

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* 1. Are you a TRICARE West beneficiary? (If your health coverage is TRICARE and you live in one of these states you may be a TRICARE West beneficiary: AZ, CA, CO, ID, IA, KS, MN, MO, MT, NE, NV, NM, ND, OR, SD, WA, WY, El Paso, TX)

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* 2. What behavior change are you wanting to make?

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* 3. Did completing this program help you determine your readiness for making your behavior change?

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* 4. How long did it take you to complete this program?

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* 5. How much do you agree with the following statements about this program?

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* 6. Which sections of this program did you find most helpful? (Choose all that apply)

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* 7. Which of the following concepts or tools did you or do you plan to use to help you make your change? (Choose all that apply)

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* 8. Now that you have completed this program, what actions do you plan to take toward your health goals? (Choose all that apply)

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* 9. This program would be better if:

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* 10. Overall, how would you rate this program?

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* 11. Please use the space below to provide additional comments about the program:

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* 12. Gender

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* 13. Age (Number format, for example, 45)

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* 14. Branch of service of the Tricare sponsor

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* 15. Duty status

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* 16. Do you receive your health care at a military hospital or clinic?

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* 17. How did you learn about this online program?

* 1. Are you a TRICARE West beneficiary?
(If your health coverage is TRICARE and you live in one of these states you may be a TRICARE West beneficiary: AZ, CA, CO, ID, IA, KS, MN, MO, MT, NE, NV, NM, ND, OR, SD, WA, WY, El Paso, TX)