Hidden field for Shazam/JS embed
1. Please choose your reason for contacting us:
Click as many as you want.
2. Tell us about your technical problem.
3. What is your e-mail address?
2. Which PREPARE tool would you like to help us improve?
Click as many as you want.
PREPARE Website language:
English
Spanish
Other
1. For which PREPARE Step would you like to provide feedback:
Face page and introduction video
Welcome page
Step 1
Step 2
Step 3
Step 4
Step 5
Next Steps
2. Please copy the url of the page you would like to provide feedback (right click on the url and select copy. Then, right click and select paste in this box).
3. Current wording: Please copy and paste (or type) the current wording here. If it is a video, please see the video script to copy and paste in wording.
4. Your proposed wording or change:
5. Reason for the change or suggestion:
PREPARE Advance Directive language:
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
1 2 3 4 5 6 7 8 8A 9 10 11 12 13 14 15 16
3. Current wording: Please copy and paste (or type) the current wording here.
4. Your proposed wording or change and reason for the change:
5. Is the proposed change based on a legal requirement in your state?
Yes
No
Please copy and paste the statute in here:
6. Are you an attorney licensed in the same state as the advance directive?
Yes
No
Would you be willing to talk to our team about your feedback?
Yes
No
PREPARE Summary of My Wishes language:
1. Current wording: Please copy and paste (or type) the current wording here.
2. Your proposed wording or change or other suggestion:
3. Reason for the change or suggestion:
PREPARE Pamphlet language:
1. Current wording: Please copy and paste (or type) the current wording here.
2. Your proposed wording or change or other suggestion:
3. Reason for the change or suggestion:
Was the movie event in English or Spanish?
1. What role did you play in the PREPARE movie group event?
Organizer
Participant
Clinician (anyone who cares for patients)
Librarian
Faith leader
Community leader
Other: _________
3. Where did the event take place?
Clinic or hospital
Library
Place of worship
Senior or community center
Nursing home or assisted living facility
Home event
Other: _________
I don't know
4. What is your zip code?
5. What was the date of your event?
Today M-D-Y
6. How many people were there?
7. The PREPARE written movie Toolkit for Group Events was easy to use.
Strongly Agree
Agree
I have no opinion
Disagree
Strongly Disagree
8. The PREPARE movie group event was easy for me to put on.
Strongly Agree
Agree
I have no opinion
Disagree
Strongly Disagree
9. The PREPARE written movie Toolkit for Group Events was helpful.
Strongly Agree
Agree
I have no opinion
Disagree
Strongly Disagree
10. I would recommend putting on a PREPARE movie group event to other people.
Strongly Agree
Agree
I have no opinion
Disagree
Strongly Disagree
11. How many people might you show the PREPARE movie Toolkit to in the next 12 months?
1-10
11-30
31-50
50 or more
I don't know
Thank you for going to the PREPARE Movie Group Event!
We hope it was helpful.
To help us improve PREPARE, please answer the following questions. For each question, tell us how much you agree or disagree.
2. The PREPARE movie was easy to understand.
Strongly agree
Agree
I have no opinion
Disagree
Strongly disagree
3. During the PREPARE movie, I was ready to answer some questions about my wishes for medical care.
Strongly agree
Agree
I have no opinion
Disagree
Strongly disagree
4. I would recommend the PREPARE movie to other people.
Strongly agree
Agree
I have no opinion
Disagree
Strongly disagree
5. Where did the event take place?
Clinic or hospital
Library
Place of worship
Senior or community center
Nursing home or assisted living facility
Home event
Other: _________
I don't know
6. What is your zip code?
7. What was the date of your event?
Today M-D-Y
8. How many people were there?
How can we make the PREPARE movie event better?
PREPARE Question Guide language?
1. Current wording: Please copy and paste (or type) the current wording here.
2. Your proposed wording or change or other suggestion:
3. Reason for the change or suggestion:
Please type your feedback here:
Thank you for your interest in partnering with PREPARE.
To begin the partnering process, please complete the information below.
What type of project is this:
Research
QI/Clinical demonstration
Both research & QI/Clinical demonstration
Other
What are the aims or goals of the project/program?
What source/organization is funding or supporting this project/program?
Today M-D-Y
Today M-D-Y
Which materials are you planning on using? Mark all that apply:
Would you like to put any of the PREPARE written PDF materials directly on your website?
Yes
No
If yes, which ones? Mark all that apply:
Would you like to put any of the PREPARE written PDF materials within your organization's printed or online booklet, workbook, or toolkit?
Yes
No
If yes, which ones? Mark all that apply:
Are you interested in placing your logo or white labeling the PREPARE website or any of the PREPARE materials?
Yes
No
If yes, which ones? Mark all that apply:
Please note: Individual user account usage data is only available for sponsored research projects in which IRB approval is obtained. Data reporting for all other purposes, including sponsored QI and clinical demonstration projects are with aggregate anonymous usage data only.
Are you interested in Date Reporting?
Yes
No
For what purpose would you like to use data reporting:
If available, please provide your licensing and/or legal contact at your organization to help expedite licensing.
* Please note: If you do not yet know this contact, this would be a good next step as it is required for any final licensing.
Thank you and someone from the PREPARE team will get back to you within the next 2 weeks.
Thank you for your interest and your patience.
How can we make PREPARE better?
Very helpful
Somewhat helpful
Not at all helpful
Would you recommend PREPARE to other people?
Yes
No
Why would you not recommend PREPARE?
Why did you come to the PREPARE website? Click on as many as you want.
Click as many as you want.
How did you hear about PREPARE?
Thank you so much for helping us improve PREPARE!
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