The Conversation Project Community Activity Survey Q1 2019

Thank you for taking the time to help The Conversation Project learn about activity happening in your region to promote conversations! We are collecting this information on an on-going, quarterly basis and hope you will take a few minutes each quarter to share your progress with us! Once collected and sorted, we will share results back with you via our newsletter. We have created a template for you to collect this information on a monthly basis, if you need one. You can find it HERE.

Please answer the following about your work from January 1, 2019 to March 31, 2019.

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* 1. From Jan. 1-Mar. 31, 2019: How many events/activities have you either presented at or hosted on the importance of conversations about advance care planning/end-of-life care? This includes in-person or virtual events (e.g. calls/webinars). And, this includes internal events (e.g. for your own staff) and external events (e.g. for those in your community)

# of events in January:

# of events in February:

# of events in March:

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* 2. From Jan. 1-Mar. 31, 2019: If you've hosted or presented at event(s), how many were in attendance across all events combined (roughly)? For example, if you presented at ten events in January that each had ten attendees, note 100. If you hosted 3 sessions in February with the same 10 people at each session, note 30. Your best estimate is OK; doesn't have to be exact numbers!

Total # of attendees in January:

Total # of attendees in February:

Total # of attendees in March:

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* 3. From Jan. 1-Mar. 31, 2019: If you’ve also shared specific TCP-related messages (e.g. any content, tools or resources highlighting the importance of conversations) through other mediums, please note roughly how many individuals you have reached below. Your best estimate is OK, doesn't have to be exact numbers! Please fill out only applicable fields.

#of TCP starter kits distributed that were not tied to an event:

# of individuals reached via a newsletter or email that contained TCP/conversation-related messages:

# of individuals reached via social media (e.g. if you reached 100 via a Facebook message, 100 via Facebook Live event and had 50 Twitter impressions, note 250):

# of individuals reached via other media events (e.g. if you reached 200 via podcast, had an audience of 1000 radio listeners and 1000 viewers of a TV spot, note 2200):

Additional comments on how you are reaching individuals (per above):

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* 4. We are interested in learning how groups may be thinking about sustainability. Are you planning this work so it continues in the long-run? If so, how? (e.g. maybe you are working with others to lead this together so it isn’t reliant on one person, or you have leadership support and are building this into standard work practice at your organization, or you have a volunteer network built up to continue this effort on their own, etc.)
Please share if applicable.

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* 5. What, if anything, would you want from TCP to help you sustain this work in the long-run?

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* 6. Optional Feedback: Now that we’ve been conducting this survey for a year, we’d love any feedback you have on this survey process and/or how we share the results we gather. Is there anything you would change or recommend we do to make this survey easier for you to fill out regularly? Are the summary results we share in our newsletter informative and/or is there another way you’d like us to share these results?

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* 7. Your Name

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* 8. Your Organization's Name and/or Your Initiative's Name

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* 9. With what type of organization are you affiliated? (Please pick the affiliation that best describes your organization.)

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* 10. E-Mail Address

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* 11. In what zipcode are you or your organization located?

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* 12. Any comments/questions (optional)

Thanks you for your participation! Please do not hesitate to contact us with any questions at conversationproject@ihi.org.