Community Engagement Survey Question Title * 1. Name of event attended: Question Title * 2. In which community was the event held? Question Title * 3. Where did you meet the Affinity Health Plan Community Engagement Representative? Community Event Provider Office Network Event Business Meeting Other (please specify) Question Title * 4. How would you rate your encounter with the Affinity Health Plan Community Engagement Representative? Great Pretty OK No Response Left Something to be desired Horrible Question Title * 5. When did you interact with an Affinity Health Plan Community Engagement Representative? Within this past week Within this month Last 3 months Over 6 months ago Question Title * 6. Were we helpful in answering your questions? Absolutely I guess So Somewhat No Response Not Really Question Title * 7. Would you keep in contact with the Affinity Health Plan Community Engagement Representative? Certainly I don't think so No Response Question Title * 8. Tell Us, Are you...... A provider Member A community/ faith based Partner Non Member A school administrator partner A government official partner Other Question Title * 9. Are you a Provider? If yes, please provide name: Question Title * 10. How do you rate the event / presentation? Great Pretty ok No Response Left something to be desired Horrible Question Title * 11. Would you attend another event presented by Affinity Health Plan? Yes, I would Perhaps No Response No, I would not Question Title * 12. Would you recommend the event to members of your community, family or friends? Yes, I would Perhaps No Response No, I would not Question Title * 13. Would you like us to bring this event into another community? Yes No Question Title * 14. Please provide your contact information to learn more about Affinity Health Plan local events: Email: Print (please provide mailing address): Phone call: Question Title * 15. How Can We Improve? Give us your suggestions. Done