Form CMS-10194 SNP-OMB Appx C FocusGroupBeneForm

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:
1.

[Preprinted]

Please indicate your gender:

DATE/TIME:
6.

MARK ONE
~ Female
~ Male
2.

MARK ONE
~ Under 65 years old
~ 65-74 years
~ 75-84 years
~ 85 years or older
3.

4.

My marital status is:
MARK ONE
~ Never married
~ Married
~ Living with partner
~ Separated
~ Divorced
~ Widowed

Excellent
Good
Fair
Poor

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:
~
~
~
~
~

I consider myself:
MARK ONE OR MORE
~ African-American (non-Hispanic)
~ Asian
~ Hispanic
~ Native American
~ Pacific Islander
~ White (non-Hispanic)
~ Other (Please Specify)

5.

7.

I am:
MARK ONE
~ Hispanic or Latino/Latina
~ Not Hispanic or Latino/Latina

My current health condition is:
~
~
~
~

Please indicate your age:

[Preprinted]

9.

Heart attack
Stroke
Heart failure
Pneumonia
Cancer

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!