Georgia Voices for Medicaid Consumer Satisfaction Survey Pre-Test (12/15)

Preliminary questions for Georgia Voices for Medicaid Consumer Satisfaction Survey

Your contact information will only be shared with GHF so that we can follow up with you after the presentation. Your contact information and individual responses will not be shared with any other organization or individual.

Question Title

* 1. Date

Date / Time

Date

Question Title

* 2. Where in Georgia are you located?

Question Title

* 3. Please enter your name.

Question Title

* 4. Please enter your email.

Question Title

* 5. Check all the boxes below that describe you.

I am a self-advocate (the practice of developmentally disabled people speaking up for themselves and controlling their own affairs.)

I am a family member of a self-advocate.

I am a professional or other.

I live in Rural Georgia (outside of a city of Georgia.)

I am a man.

I am a woman.

My gender is non-binary.

I prefer not to tell you my gender.

I am white.

I am Native Hawaiian or other Pacific Islander.

I am Asian.

I am Native American/American Indian.

I am Hispanic/Latino.

I am two or more races.

I am Black or African American.

I don't know my race/I choose not to tell you what my race is.

Question Title

* 6. I am interested in learning more about the Georgia Health Action Network.

Yes

Georgia Voices for Medicaid Consumer Satisfaction Survey Pre-Test (12/15)

Preliminary questions for Georgia Voices for Medicaid Consumer Satisfaction Survey

Question Title

* 1. Date

Question Title

* 2. Where in Georgia are you located?

Question Title

* 3. Please enter your name.

Question Title

* 4. Please enter your email.

Question Title

* 5. Check all the boxes below that describe you.

Question Title

* 6. I am interested in learning more about the Georgia Health Action Network.

Question Title

* 7. Zoom Link