Form 1 Senior Medicare Patrol Comment Card Survey

OMB. No. 0985-xxxx
xx/xx/2020

Medicare Fraud Event Survey
The following questions ask about the presentation you recently attended. Please answer all of the questions
and leave the comment card with the presenter when you finish. Thank you!
1. How did you learn about today’s presentation? (mark all that apply)
A Event location announcement (e.g., senior
E Website
center, library)
F Previous presentation
B Mailing
G TV, radio, or newspaper
C Friend or relative
H Flyer
D Another agency
I Other (please specify_______________)

For questions 2 – 6, mark how much you agree or
disagree with the following statement(s):

Strongly
Agree
Agree

2. It was easy to find the details of the
presentation, such as date, time, location, and
topic.
3. This presentation provided me with useful
information.
4. Overall, I am satisfied with the presentation
today.
5. I would contact the presenter for help or
information.
6. I would recommend this presentation to others.

Neither
Agree nor
Disagree

Disagree

Strongly
Disagree

A

B

C

D

E

A

B

C

D

E

A

B

C

D

E

A

B

C

D

E

A

B

C

D

E

7. Based on what you learned today, what will you do differently? (mark all that apply)
A I will hang up on anyone who calls and asks for my Medicare number or personal information.
B I will review my Medicare Summary Notices (MSNs) or plan statements for possible errors or
fraudulent charges.
C I will report suspected Medicare fraud, errors, or abuse.
D I will share what I learned with my family or friends.
E Other action (please specify__________________________________________________________).
F Not applicable/I will not do anything differently.
8. What could we do to improve the information or service(s) provided to you today?

Presentation information to be completed by SMP official:
Time:
Date:
/
/
Name of Presenter/SMP Official:________________________

Location: