TakeCHARGE 5 Steps to Safer Health Care

This survey is intended to learn whether the TakeCHARGE Campaign assisted you in becoming a better-prepared patient. TakeCHARGE: 5 Steps to Safer Health Care is a year-long program that encourages people to perform 5 Steps to becoming well-prepared patients. TakeCHARGE began as a campaign in March 2020 and each month following, one of the 5 Steps was used to motivate the public to take one of these simple steps that contribute to a clear patient-provider relationship and help ensure safer care. If you have questions about this survey, contact Pulse Center for Patient Safety at (516)579-4711.

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1. How did you receive this survey?

E-mail

Website

Social Media

Other (please specify)

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2. Before this survey, did you know about TakeCHARGE? (Choose one.)

I never heard of TakeCHARGE

I heard of it but didn’t know what it was

I heard of it and followed it

I was involved in TakeCHARGE Campaign out reach

Other (please specify)

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3. Did you see a presentation or any material related to TakeCHARGE? (Check all that apply.)

I attended a 10-minute online (Zoom) introduction video

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4. Did you see a presentation or any material related to TakeCHARGE? (Check all that apply.)

I attended a 10-minute online (Zoom) introduction video

I attended a 10-minute voice call introduction

I attended a one-hour online (Zoom) introduction video

I attended a one-hour voice call introduction

I participated in the 4-hour Ambassador Training on certain dates

I attended programs where there was discussion and speakers

I attended a discussion group(s)

Someone told me about TakeCHARGE

I saw a video or videos on the TakeCHARGE website or social media

I received written material by Email

I received written material on Social Media

Other (please specify)

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5. I followed TakeCHARGE on these social media (check all that apply):

Facebook

Twitter

Instagram

Other (please specify)

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6. I heard or saw information on individual Steps (check all that apply):

1. Understand & Complete Your Advance Directives (April)

2. Keep a Record of Your Medical History & Current Medications (May)

3. Prepare for Doctor Visits / Make A List of Questions (June)

4. Prevent Infections / Ask Caregivers to Wash Their Hands (July)

5. Use an Advocate / Be an Advocate for Others (August)

Other (please specify)

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7. Because of TakeCHARGE: (check all that apply):

I completed my advance directives (Healthcare Proxy)

I created or updated my medications list

I created or updated my personal medical records and history

I developed a list of questions for my next medical appointment

I wrote a list of my symptoms before a medical appointment

I noticed if a clinician or caregiver washed their hands

I saw a clinician or caregiver not wash their hands and asked them to wash

I saw a clinician or caregiver not wash and did not ask them to wash

I chose someone to be my patient advocate

I offered to be an advocate for someone else

I was an advocate for someone else

Other (please specify)

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8. Did you share TakeCHARGE with someone else? (Check all that apply):

Family

Friends

Business colleagues

No, I did not share the information

Other ways you shared information

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9. Age

Under 18

18-24

25-34

35-44

45-54

55-64

65+

TakeCHARGE 5 Steps to Safer Health Care

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1. How did you receive this survey?

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2. Before this survey, did you know about TakeCHARGE? (Choose one.)

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3. Did you see a presentation or any material related to TakeCHARGE? (Check all that apply.)

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4. Did you see a presentation or any material related to TakeCHARGE? (Check all that apply.)

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5. I followed TakeCHARGE on these social media (check all that apply):

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6. I heard or saw information on individual Steps (check all that apply):

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7. Because of TakeCHARGE: (check all that apply):

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8. Did you share TakeCHARGE with someone else? (Check all that apply):

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9. Age

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10. Zip Code

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11.

Please write in any other feedback you have about the TakeCHARGE Campaign:

TakeCHARGE 5 Steps to Safer Health Care

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* 1. How did you receive this survey?

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* 2. Before this survey, did you know about TakeCHARGE? (Choose one.)

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* 3. Did you see a presentation or any material related to TakeCHARGE? (Check all that apply.)

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* 4. Did you see a presentation or any material related to TakeCHARGE? (Check all that apply.)

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* 5. I followed TakeCHARGE on these social media (check all that apply):

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* 6. I heard or saw information on individual Steps (check all that apply):

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* 7. Because of TakeCHARGE: (check all that apply):

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* 8. Did you share TakeCHARGE with someone else? (Check all that apply):

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* 9. Age

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* 10. Zip Code

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* 11. Please write in any other feedback you have about the TakeCHARGE Campaign:

1. How did you receive this survey?

2. Before this survey, did you know about TakeCHARGE? (Choose one.)

3. Did you see a presentation or any material related to TakeCHARGE? (Check all that apply.)

4. Did you see a presentation or any material related to TakeCHARGE? (Check all that apply.)

5. I followed TakeCHARGE on these social media (check all that apply):

6. I heard or saw information on individual Steps (check all that apply):

7. Because of TakeCHARGE: (check all that apply):

8. Did you share TakeCHARGE with someone else? (Check all that apply):

9. Age

10. Zip Code

11.

Please write in any other feedback you have about the TakeCHARGE Campaign: