The Conversation Project Community Activity Survey Q4 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 October 1, 2019 to December 31, 2019.

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* 1. Your Name

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* 2. E-Mail Address

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

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

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

We will be hosting several coaching calls across 2020 aimed to tackle a burning question or issue. Please answer the below questions (6 & 7) with anything you would like us to include.

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* 6. What’s the biggest question or challenge you face that you would like help with brainstorming some possible solutions?

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* 7. On the flip side, what was the biggest challenge you faced and tackled successfully that you think others may learn from?

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* 8. We love hearing your stories! Tell us what you are doing in your community, a story that would inspire, and/or one standout from the quarter or year – we’d love to hear it!

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* 9. From October 1, 2019 to December 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 October:

# of events in November:

# of events in December:

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* 10. From October 1, 2019 to December 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 July that each had ten attendees, note 100. If you hosted 3 sessions in August 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 October:

Total # of attendees in November:

Total # of attendees in December:

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* 11. From October 1, 2019 to December 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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* 12. If you missed completing a survey earlier in 2019, please share the number of events and attendees not previously reported for the year (optional):

# Events

# Attendees

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* 13. We love to share any great ideas we learn in our survey across our various platforms and credit the groups that share with us. Please check here If you are NOT willing to have your organization/name included in our newsletter/blog write-ups.

By checking here, we will NOT share your name/organization and keep anything shared anonymous.

Please do NOT share my name/organization and keep anything shared anonymous.

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* 14. For those new to TCP, how did you hear about/connect with us? (optional)

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* 15. Any comments/questions? Or please share any special projects, achievements, challenges, or lessons learned (optional)

Thank you for your participation! If you haven’t already, connect with others doing similar work by adding your pin to our Conversation Champions Map.

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Please do not hesitate to contact us with any questions at conversationproject@ihi.org.