Summary of Changes

EVALUATION OF FROM COVERAGE TO CARE IN
COMMUNITIES
Appendix E
Listing of Survey Changes with Reinstatement
(CMS-10632; OMB 0938-1342)

NOTE: Blue italicized headers indicate the reasons for changes from the prior surveys. Changes
from the previously approved surveys appear in green text.

Partner Survey Additions/Changes
Surveyi ng Those Not Using C 2C M ate ri al s
Are you a person in your organization who is knowledgeable about resources that aim to help
people with new health care coverage understand their benefits and connect to primary care?
•
•

Yes [START AT ITEM 1]
No [CONTINUE]

Would you please provide the name, email, and phone number of the person within your
organization who is knowledgeable about these matters? ____
Have you ever heard of the From Coverage to Care program through CMS, which aims to help
people with health care coverage understand their benefits and connect to primary care?
a. Yes
b. No
Does your organization rely on an outside source for information and materials (such as
pamphlets, posters, or websites) to help people with health care coverage understand their
benefits and connect to primary care?
a. Yes
b. No [SKIP TO MODULE 6]
Where do you go for information and materials to help people understand their health care
coverage and connect to primary care? (OPEN-ENDED RESPONSE)
How did you first learn about [RESPONSE 7 NAME]? From.. (Please check all that apply)
a. [RESPONSE 7 NAME] website
b. [RESPONSE 7 NAME] correspondence such as newsletter or
distribution list
c. Webinar where [RESPONSE 7 NAME] was discussed
d. [RESPONSE 7 NAME] office/distribution

e.
f.
g.
h.
i.
j.
k.

Another organization in my community
A professional organization/society
A person in my community
The media
Online search
Don’t know
Other (please specify: _________________)

When did you first learn about [RESPONSE 7 NAME]? (Choose most appropriate estimate)
a. In the last six months
b. Between six and twelve months ago
c. More than a year ago
e. Don’t know
Snowball Sampling Question. We are trying to identify organizations that might benefit from
C2C materials, but who are not currently using C2C materials. Are there other organizations in
your area that provide services to health care consumers that are similar to the services you
provide? [IF YES] Would you indicate the name of the organization, the name of the contact
person, the phone number of the contact person, and the email address of the contact person? We
would like to contact them for a similar survey. It is OK if you do not know all of this
information. Please list the information that you know. ______

Getti ng Addi ti onal Informati on on Organizati ons
How many unpaid volunteers does your organization have in total? (Please choose most
appropriate)
a. Small (less than 25 volunteers)
b. Medium (26-99 volunteers)
c. Large (100-249 volunteers)
d. Very large (250+ volunteers)
How long have you worked at the organization?
a. Less than one year
b. 1 year to less than 4 years
c. 4 years to less than 6 years
d. 6-10 years
More than 10 years

C hange s to Ite ms to Refle ct C urrent C 2C Efforts
When did your organization first learn about C2C? (Choose most appropriate estimate)
a.
In the last six months
b.
Between six and twelve months ago
c.
One to two years ago
d.
Three to five years ago
e.
More than five years ago
f.
Don’t know

Which C2C materials did your organization order? Please select all that apply (Include
categorized list of materials in drop box)
a. Roadmap to Better Care
b. A Roadmap to Behavioral Health and a Healthier You
c. Roadmap Poster Tabloid
d. Step 1: Put Your Health First
e. Step 2: Understand Your Health Coverage
f. Sample Insurance Card
g. Step 3: Know Where to Go
h. Differences Between Your Provider's Office and the Emergency
Department
i. Step 4: Pick a Provider
j. Step 5: Make an Appointment
k. Step 6: Be Prepared for Your Visit
l. Step 7: Decide if the Provider is Right for You
m. Step 8: Next Steps After Your Appointment
n. Sample Explanation of Benefits
o. 5 Ways to Make the Most of Your Health Coverage
p. Preventive Services Flyer
q. Coronavirus and Your Health Coverage: Get the Basics
r. Stay Safe: Getting the Care You Need, at Home
s. [ADDITION OF FUTURE MATERIALS]
t. Other (specify _______)
How does your organization share C2C information and materials with patients and other
members of your community? (Please choose all that apply)
a. Hand out materials and talk about them during community health fairs
b. Hand out materials and talk about them during health insurance
enrollment sessions
c. Use materials in courses/training we offer
d. Place materials on table or wall displays in our organization or other
public spaces for community members to pick up
e. Distribute materials to other partner organizations who pass them out
f. Mail materials to community members
g. Hand out or mail materials in response to community member requests
h. Re-post C2C materials directly on our website
i. Social media (e.g., Facebook, Twitter)
j. Email or email listservs
k. Text messaging (i.e., SMS, MMS)
l. Other (please specify: _________________________)
Of the ways selected in the last question, in your experience, what forms of sharing C2C
materials were most helpful to community members? (Please choose top 3)
a. Hand out materials and talk about them during community events/health
fairs
b. Hand out materials and talk about them during enrollment sessions
c. Use materials in courses/training we offer
d. Place materials on table or wall displays in our organization or other
public spaces for community members to pick up
e. Distribute materials to other organizations who pass them out

f.
g.
h.
i.
j.
k.
l.

Mail materials to community members
Hand out or mail materials in response to community member requests
Re-post C2C materials directly on our website
Social media (e.g., Facebook, Twitter)
Email or email listservs
Text messaging (i.e., SMS, MMS)
Other (please specify: _________________________)

How has your organization shared C2C materials and messages with other organizations in your
community? (Please choose all that apply)
a. Told colleagues or other community organizations about C2C
b. Mailed C2C materials to other organizations
c. Distributed C2C materials to other organizations at community events
(for example, at a health fair)
d. Presented C2C information to organizations (for example, at a local
meeting)
e. Re-post C2C materials directly on our website
f. Social media (e.g., Facebook, Twitter)
g. Email or email listservs
h. Text messaging (i.e., SMS, MMS)
i. Other (Please specify: _______________)
j. We have not shared materials
In your experience, what form of sharing C2C materials with other organizations was most
helpful to them? (Please choose one)
a. Told colleagues or other community organizations about C2C
b. Mailed C2C materials to other organizations
c. Distributed C2C materials to other organizations at community events
(for example, at a health fair)
d. Presented C2C information to organizations (for example, at a local
meeting)
e. Re-post C2C materials directly on our website
f. Social media (e.g., Facebook, Twitter)
g. Email or email listservs
h. Text messaging (i.e., SMS, MMS)
k. Other (Please specify: _______________)
When it comes to health care in your community, what would you say are the biggest barriers
individuals face? [PLEASE RANK TOP 3 CHOICES]
a. Individuals do not know how to access health care services
b. Individuals do not know how to find a regular provider or source of care
c. Individuals do not understand the importance of health care
d. Individuals do not understand the importance of health insurance
e. Individuals do not understand how to use their insurance benefits
f. Individuals do not understand when it is appropriate to use emergency or
urgent care services
g. Individuals do not understand how to access health services online (e.g.,
patient portals)
h. Individuals do not have the resources (e.g., electronic devices, internet
access) to access health services online (e.g., patient portals)

i.

Individuals do not understand the importance of preventive health
services (e.g., vaccinations, screenings)
j. Individuals do not understand how to stay safe when there are publichealth concerns (e.g., COVID-19, SARS)
k. Individuals do not understand how to access health care services when
there are public-health concerns (e.g., COVID-19, SARS)
l. Other (please specify:)______________
For the next four questions, consider if the following issues would be considered a priority for
your organization and if any messaging was used on the topic.

Access to health
services

A. Is this topic an
area of focus or a
top priority of
your
organization?
(Yes/No drop
down menu –
SKIP part B if
NO)

Find a regular
provider or
source of care

(Yes/No drop
down menu –
SKIP part B if
NO)

Understand
insurance benefits
and how to use
insurance

(Yes/No drop
down menu –
SKIP part B if
NO)

Access
appropriate
care/services

(Yes/No drop
down menu –
SKIP part B if
NO)

B. Did your organization use any messaging or
materials in its work on this topic? (Please choose all
that apply) [OPTIONS A & B HIDDEN IF NOT
C2C AWARE AND NOT ORDERED]
a. Used C2C materials on this topic
b. Adapted C2C materials to our community’s
needs
c. Used other materials on this topic (please
specify: ___________________)
d. Created our own materials/messages on this
topic
a. Used C2C materials on this topic
b. Adapted C2C materials to our community’s
needs
c. Used other materials on this topic (please
specify: ___________________)
d. Created our own materials/messages on this
topic
a. Used C2C materials on this topic
b. Adapted C2C materials to our community’s
needs
c. Used other materials on this topic (please
specify: ___________________)
d. Created our own materials/messages on this
topic
a. Used C2C materials on this topic
b. Adapted C2C materials to our community’s
needs
c. Used other materials on this topic (please
specify: ___________________)
d. Created our own materials/messages on this
topic

Members of my community are better prepared to deal with public health concerns (e.g., COVID19, SARS).
• Strongly disagree

•
•
•
•
•

Disagree
Neutral
Agree
Strongly agree
Don’t know/I don’t work with the community directly

Members of my community …
a. Are aware of online portals (e.g., insurance, hospital, doctor office).
b. Know how to use online portals.
c. Have lots of questions about how to use online portals.
• Strongly disagree
• Disagree
• Neutral
• Agree
• Strongly agree
• Don’t know/I don’t work with the community directly
d. [ASK IF Agree OR Strongly Agree TO 34d] Would you please list some
examples of questions that members of your community have about
online portals.
After seeing or using C2C materials… Organizations in my community felt more prepared to deal
with public health concerns (e.g., COVID-19, SARS).
• Strongly disagree
• Disagree
• Neutral
• Agree
• Strongly agree
• Don’t know/I didn’t share materials with other organizations
After using C2C materials…
a. Navigators learned more about why prevention and primary care is
important for consumer health.
b. Navigators learned more about health insurance and how to use it.
c. Navigators learned more about helping people choose coverage that best
meets their needs and expectations.
d. Navigators learned more about inappropriate use of emergency or urgent
care.
e. Navigators learned more about encouraging the use of more regular and
or/preventive care.
e. Navigators learned more about helping people find a provider and make
an appointment.
• Strongly disagree
• Disagree
• Neutral
• Agree
• Strongly agree
• Don’t know/I didn’t share materials with Navigators

[For responses of very helpful or helpful, ask] Why was that material helpful to your
organization? (please choose all that apply)
a. It addressed one of the biggest health care-related problems or needs in
my community.
b. It was the easiest set of materials for our organization to communicate
with community members.
c. It was the easiest set of materials for community members to understand.
d. Health care navigators learned a lot from these materials.
e. Other (please specify: _____________________)
[For responses of very unhelpful or unhelpful, ask] Why was that material unhelpful to your
organization? (please choose all that apply)
a. It did not address relevant needs in my community.
b. It was the most difficult set of materials for our organization to
communicate with community members.
c. It was the most difficult set of materials for community members to
understand.
d. Health care navigators did not learn much from these materials.
e. Other (please specify: _____________________)
Has your organization used any of the C2C online resources? (check all that apply)
a. Someone in our organization has visited the C2C website.
b. Someone in our organization has downloaded C2C materials.
c. Someone in our organization has watched the C2C videos available on
the website.
d. Our organization uses the C2C website or other online resources to
discuss C2C topics with community members/patients.
e. Other (please specify): _________________________
f. No one has used C2C online resources.

Consumer Survey Additions/Changes
Addi tional Relevant Items Available i n Ipsos K nowle dge Panel
Gender
Age
Marital status
• Married
• Widowed
• Divorced
• Separated
• Never married
• Living with partner
Children

• Age
• Gender
• Number
Education
• No formal education
• 1st, 2nd, 3rd, or 4th grade
• 5th or 6th grade
• 7th or 8th grade
• 9th grade
• 10th grade
• 11th grade
• 12th grade, no diploma
• High school graduate—high school diploma or the equivalent (GED)
• Some college, no degree
• Associate’s degree
• Bachelor’s degree
• Master’s degree
• Professional or doctorate degree
Race
• White
• Black or African American
• American Indian or Alaska Native
• Asian
• Native Hawaiian/Pacific Islander
• 2+ races
Hispanic origin
• Mexican, Mexican-American, Chicano
• Puerto Rican
• Cuban, Cuban American
• Other Spanish/Hispanic/Latino
Household income
• Less than $5,000
• $5,000 to $7,499
• $7,500 to $9,999
• $10,000 to $12,499
• $12,500 to $14,999
• $15,000 to $19,999
• $20,000 to $24,999
• $25,000 to $29,999
• $30,000 to $34,999
• $35,000 to $39,999
• $40,000 to $49,999
• $50,000 to $59,999
• $60,000 to $74,999
• $75,000 to $84,999
• $85,000 to $99,999
• $100,000 to $124,999

• $125,000 to $149,999
• $150,000 to $174,999
• $175,000 to $199,999
• $200,000 to $249,999
• $250,000 or more
Home ownership
• Owned or being bought by you or someone in your household
• Rented for cash
• Occupied without payment of cash rent
Domicile location
• ZIP code
• County
• Metro area
• Urban/suburban/rural
• DMA
• State
• Region
Household head (yes/no)
Empty-nester (yes/no)
Internet access
• By paying a cell phone company or internet service provider
• Without paying a cell phone company or internet service provider
• No access to the internet in my house, apartment, or mobile home
Personal/household Internet use locations
• Home
• Work
• School or library
• Another place
Personal/household Internet access mode at home
• Cellular data plan for a smartphone or other mobile device
• High-speed Internet service such as cable, DSL, or fiber-optic service
• Satellite Internet service
• Dial-up service
• Other service
Employment status
• Working—as a paid employee
• Working—self-employed
• Not working—on temporary layoff from a job
• Not working—looking for work
• Not working—retired
• Not working—disabled
• Not working—other

Employed full time or part time (yes/no, of employed)
Currently a student (yes/no, of students)
Currently a stay-at-home spouse or partner (yes/no)
Sexual orientation
• Gay or Lesbian
• Straight, that is, not gay
• Bisexual
• Something else
Gender identity
• Cisgender
• Transgender
• Other
U.S. citizenship
• Born a citizen
• Naturalized citizen
• Not a citizen
Self-reported health status (options not presented in reference)
Height/weight/BMI
Personal medical conditions
• Acid reflux disease
• ADHD or ADD
• Asthma, chronic bronchitis, or COPD
• Cancer
• Concussion
• Chronic pain (such as low back pain, neck pain, or fibromyalgia)
• Diabetes or pre-diabetes
• Eye condition (other than poor vision)
• Gastrointestinal condition
• Heart attack, heart disease, or other heart condition
• Hepatitis C
• High blood pressure
• High cholesterol
• HIV/AIDS
• Inflammatory Bowel Disease (IBD) (such as Ulcerative colitis or Crohn’s disease)
• Kidney disease
• Menopause or perimenopause
• Migraines
• Multiple sclerosis
• Nonalcoholic fatty liver disease
• Osteoarthritis, joint pain, or inflammation
• Osteoporosis or osteopenia
• Psoriasis
• Pulmonary Arterial Hypertension (PAH)

• Rheumatoid arthritis
• Seasonal allergies
• Sexual dysfunction
• Sleep disorders such as sleep apnea or insomnia
• Stroke
• Traumatic brain injury
• Uterine fibroids
Personal mental health conditions
• Anxiety disorder
• Bipolar disorder
• Depression
• Mood disorders
• Schizoaffective disorder
• Schizophrenia
Diagnosed with Type 1 diabetes/Type 2 diabetes/Pre-diabetes or IGT
How diabetes is managed (options not presented in reference, of those with diabetes)
Type of cancer diagnosis (options not presented in reference, of those with diabetes)
Frequency of VIGOROUS exercise and frequency of LIGHT OR MODERATE exercise (options
not presented in reference)
Type of health insurance
• Through own or someone else’s employer or union
• Medicare
• Medicaid or a state medical assistance plan
• Health insurance you bought through an insurance exchange
• Veteran’s Affairs, Department of Defense, or other military program
• Health insurance from some other source
Ever covered by health insurance purchased through a state or federal exchange (yes/no)
Year in which first purchased health insurance through an exchange (yes/no, of those purchasing
exchange plan)
Sources of health information in past 12 months
• Doctor
• Pharmacist
• Nurse, nurse practitioner, or physician’s assistant
• Relative, friend, or co-worker
• Someone you know who has a particular medical condition
• Disease-related association or society
• Patient support group or foundation
• Educational forum at a local clinic, hospital, community center, or other location
• Pharmaceutical company
• Health insurance company
• Newspapers or magazines
• Television

• The internet
• Social media
• Health care app
Attitudes about vaccination (options not presented in reference)

C hange s Due to Al so Inte rvie wi ng Pe ople with M arketpl ace Pl ans
[SCREENER]
KnowledgePanel records indicate that you have health insurance through [POPULATE WITH
Medicare / Medicaid or a state medical assistance plan / Health insurance you bought through an
insurance exchange]. Is this still your insurance provider?
• Yes [CONTINUE]
• No [ASK INSURANCE TYPE QUESTION AND CONTINUE ONLY IF ONE OF
THREE SELECTED INSURERS]
• Don’t know [END SURVEY]

Me asure s of Additi onal Relevant C onstructs and Re fine me nt of Pri or
Me asure s
Health Insurance Literacy
Please assume the following information is on your health insurance card. Please refer to this card
to answer the following questions…
INSURANCE COMPANY NAME
Plan type: PPO

Member Name: Jane Doe
Member Number: 123-45-678

Effective Date: 12/21/2019
Group Number: 98765-432
Prescription Group #: 13579
Prescription Copay:
$15.00 Generic
$20.00 Name brand

PCP Copay: $15.00
Specialist Copay: $25.00
Emergency Room Copay: $75.00

Member Service: 800-123-4567

a. Your doctor’s office asks you for your health insurance member number. Please enter
it here: ______
b. The pharmacy fills a generic prescription for you. How much money total will you
need to pay out of your own pocket for this prescription? ______
c. You have forgotten to mail in your monthly insurance premium and you are not sure
what to do. What number should you call? ______

d. Your doctor’s office asks you if you have a PPO (preferred provider organization) or
an HMO (health maintenance organization). Which do you have? ______
e. You have visited your primary care physician, because of a cold that will not go
away. How much will you have to pay out of pocket for the visit? ______
f. This is your first insurance plan you have enrolled in. You visited the ER on
12/19/2019. Will this insurance plan cover the services you received? yes/no
g. Will you have to pay more out of pocket for an ER visit or a PCP visit? PCP/ER
h. Your pharmacist asks you if you want the brand name prescription or you would like
the generic alternative. How much more money will you need to pay out of your
pocket for the brand name? ______

Functional Health Literacy
This information is on the back of a container of a pint of ice cream.

•
•
•

•

If you eat the entire container, how many calories will you eat? [Answer: 1,000 is the
only correct answer]
If you are allowed to eat 60 grams of carbohydrates as a snack, how much ice cream
could you have? [Answer: Any of the following is correct: 1 cup (or any amount up to 1
cup), half the container.]
Your doctor advises you to reduce the amount of saturated fat in your diet. You usually
have 42 g of saturated fat each day, which includes one serving of ice cream. If you stop
eating ice cream, how many grams of saturated fat would you be consuming each day?
[Answer: 33 is the only correct answer]
If you usually eat 2,500 calories in a day, what percentage of your daily value of calories
will you be eating if you eat one serving? [Answer: 10% is the only correct answer]

Pretend that you are allergic to the following substances: penicillin, peanuts, latex gloves, and bee
stings.
•
•

Is it safe for you to eat this ice cream? [yes/no; Answer: No]
(Ask only if the patient responds “no” to question 5): Why not? [Answer: Because it has
peanut oil.]

General Health Literacy
How confident are you filling out medical forms by yourself?
o Extremely confident
o Quite confident
o Somewhat confident
o A little confident
o Not at all confident
Provider Fosters Health Literacy
These next questions ask about the person or place from whom you receive most of your health
care services. This is often referred to as your provider. With this provider in mind, how often…
•
•
•
•
•

Does this provider give you all the information you want about your health?
Does this provider encourage you to talk about all your health problems or concerns?
Does this provider ask you to repeat back or describe how you are going to follow their
instructions?
Did this provider give you easy to understand instructions about how to take your
medicines?
Are the results of your blood test, x-ray, or other test easy to understand?
o Never
o Almost never
o Sometimes
o Usually
o Almost always
o Always

Self-Reported Use of Preventive Services
About how long has it been since you had bloodwork to try to prevent future health problems?
o Within past 12 months
o Within past 1-2 years
o Within past 3-4 years
o Within past 5-6 years
o More than 7 years
o Never
o Don’t know
Do you have Hypertension, Diabetes, or Heart Disease?
• Yes [ASK NEXT QUESTION]
• No [SKIP TO 22]
• Don’t Know [SKIP TO 22]

Has a doctor given you instructions on how to manage your condition?
• Yes [ASK NEXT QUESTION]
• No [SKIP TO 20]
• Don’t Know [SKIP TO 20]
Have you generally followed your doctor’s instructions?
• Yes
• No
• Don’t Know
Have you received regular diagnostic tests (blood pressure, A1C, and/or cholesterol count) for
your chronic condition?
• Yes [ASK NEXT QUESTION]
• No [SKIP TO 22]
• Don’t Know [SKIP TO 22]
Have your test results been within the acceptable range your doctor mentioned?
• Yes
• No
• Don’t Know
Have you taken a test to see if you have COVID-19 (also called the coronavirus or SARS-CoV2)?
o Yes
o No
o Don’t know
Domain: Patient-Centeredness of Experience
How often do providers:
• Give you the chance to ask all the health-related questions you have?
• Give the attention you need to your feelings and emotions?
• Involve you in decisions about your health care as much as you want?.
• Make sure you understand the things you need to do to take care of your health?
• Explain things in a way you can understand?
• Spend enough time with you.?
• Help you deal with feelings of uncertainty about your health or health care?
o Always
o Often
o Sometimes
o Never
Domain: Discrimination in Medical Settings
Please indicate how often each of the following happen when you are receiving medical services.
• You are treated with less courtesy than other people.
• You are treated with less respect than other people.
• You receive poorer service than others.

•
•
•
•

A doctor or nurse acts as if he or she thinks you are not smart.
A doctor or nurse acts as if he or she is afraid of you.
A doctor or nurse acts as if he or she is better than you.
You feel like a doctor or nurse is not listening to what you were saying.
o Never
o Rarely
o Sometimes
o Most of the time
o Always

Miscellaneous Refinements
Tell me which of these apply to your last urgent care visit? Check all that apply.
o The doctor’s office did not have any available sick appointments
I feel confident that I know…
• When to go to my doctor or another health care professional instead of going to the
emergency room or an urgent care.
• When to go to an urgent care instead of going to my doctor or another health care
professional or the emergency room.
• When to go to the emergency room instead of going to my doctor or another health care
professional or an urgent care.
o Not at all confident
o Slightly confident
o Moderately confident
o Very confident
If you needed or wanted to see a behavioral or mental health professional such as a psychiatrist,
psychologist, psychiatric nurse, or clinical social worker, do you know how to get this care?
• Yes
• No
During the past 12 months, how many times have you needed information or materials to help
you understand your health insurance coverage or insurance terms?
o Not at all [SKIP NEXT ITEM]
o Once
o 2 to 4 times
o 5 to 10 times
o More than 10 times
During the past 12 months, how many times have you sought out health insurance information or
materials to help you understand your health insurance coverage or insurance terms?
o Not at all
o Once
o 2 to 4 times
o 5 to 10 times
o More than 10 times

C hange s to Ite ms to Refle ct C urrent C 2C Efforts

How do you prefer to see or receive resources that help you understand your health insurance
coverage or insurance terms? Please rank the top three sources you use.
o From an assister or navigator while enrolling in health insurance
o At your provider’s office or other health care setting
o Event (i.e., a community event, health promotion fair, etc.)
o From an informational table or bulletin board (e.g., at a community organization or
library)
o Online (e.g., by visiting a website)
o Social media (Facebook, Twitter, etc.)
o Print (Newspaper, magazine, poster, etc.)
o Mail
o Radio
o Television
o I do not know where to find resources on health insurance
o Other: _________________
Please indicate the extent to which you agree or disagree that From Coverage to Care (C2C)
materials encouraged you to obtain health insurance or continue your health insurance coverage.
• Strongly Disagree
• Disagree
• Agree
• Strongly Agree
Have you seen From Coverage to Care’s (C2C): “A Roadmap to Better Care and a Healthier
You”?
• Yes [ASK NEXT QUESTION]
• No [SKIP TO ITEM 47]
• Don’t Know [SKIP TO ITEM 47]
Have you seen [INSERT C2C MATERIAL NAME]?
• Yes [ASK NEXT QUESTION]
• No [SKIP TO ITEM 51]
• Don’t Know [SKIP TO ITEM 51]
Please rate the following statements to indicate how your understanding of the following topics
have changed as a result of seeing [INSERT C2C MATERIAL NAME]?
• [Insert Learning Objective 1]
• [Insert Learning Objective 2]
• [Insert Learning Objective 3]
• [Insert Learning Objective 4]
• [Insert Learning Objective 5]
• Other: ___________________
o My understanding is the same as it was before I saw C2C materials.
o I have a slightly better understanding.
o I have a better understanding.
o I have a much better understanding.
Please indicate the extent to which you were satisfied with [INSERT C2C MATERIAL
NAME]?

•
•
•
•
•

[Insert Learning Objective 1]
[Insert Learning Objective 2]
[Insert Learning Objective 3]
[Insert Learning Objective 4]
[Insert Learning Objective 5]
o Very Satisfied
o Satisfied
o Dissatisfied
o Very Dissatisfied

Please indicate the extent to which you agree that [INSERT C2C MATERIAL NAME]?
• [Insert Learning Objective 1]
• [Insert Learning Objective 2]
• [Insert Learning Objective 3]
• [Insert Learning Objective 4]
• [Insert Learning Objective 5]
o Strongly Disagree
o Disagree
o Agree
o Strongly Agree