CMS-10194 SNP-OMB Appx C Focus Group Bene Form

SPECIAL NEEDS PLANS (SNP) FOCUS GROUP

PARTICIPANT INFORMATION FORM

Please do not include your name or address on this form. The information will be used only to summarize participant information for this meeting.

LOCATION: [Preprinted]

D ATE/TIME: [Preprinted]

1. Please indicate your gender:

MARK ONE

 Female

 Male

2. Please indicate your age:

MARK ONE

 Under 65 years old

 65-74 years

 75-84 years

 85 years or older

3. I am:

MARK ONE

 Hispanic or Latino/Latina

 Not Hispanic or Latino/Latina

4. I consider myself:

MARK ONE OR MORE

 African-American (non-Hispanic)

 Asian

 Hispanic

 Native American

 Pacific Islander

 White (non-Hispanic)

5. My marital status is:

MARK ONE

 Never married

 Married

 Living with partner

 Separated

 Divorced

 Widowed

6. My current health condition is:

 Excellent

 Good

 Fair

 Poor

7. A doctor has told me that I have:

 Heart failure

 Diabetes

 High blood pressure

 Emphysema or chronic obstruction
pulmonary disease

 Arthritis

8. I have been hospitalized within the past five years for:

 Heart attack

 Stroke

 Heart failure

 Pneumonia

 Cancer

9. I last saw a doctor:

 within the past week

 within the past two weeks

 within the past month

 more than a month ago

10. I now live:

 in my own house/apartment

 in my son’s or daughter’s
house/apartment

 in an assisted living apartment

 in a nursing facility

 somewhere else (Please Specify)

___________________________

THANK YOU FOR YOUR HELP!