The TakeCHARGE Campaign Step #1 Advance Directives

The TakeCHARGE Campaign encourages people to be informed and active participants in their health care by planning ahead before becoming patients, using the 5 Steps to Safer Health Care!

The TakeCHARGE Campaign is an ambitious public awareness campaign that has significant potential to improve patient outcomes and safety.

Thank you for helping by completing this short survey and sharing it with others.

The first two questions are for demographics.

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* 1. Age

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 2. Zip Code

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* 3. Are you familiar with the term "Advance Directive?"

Yes

Not sure

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* 4. Do you currently have an Advance Directive form that appoints a trusted person who knows your wishes to make health care decision for you if you are unable to speak for yourself in an emergency or medical event?

Yes

Not sure

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* 5. If you have an Advance Directive where do you keep it?

I have a copy

The person I chose has a copy

My doctor has a copy

I keep a copy in a folder at home

I keep it at work

I keep it with other important papers

I have a copy in my wallet

Other (please specify)

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* 6. Has the TakeCHARGE Campaign influenced your thoughts or behavior about advance directives? Please rate on a scale of 1-10 with 10 being strongly influenced.

The TakeCHARGE Campaign Step #1 Advance Directives

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* 1. Age

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* 2. Zip Code

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* 3. Are you familiar with the term "Advance Directive?"

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* 4. Do you currently have an Advance Directive form that appoints a trusted person who knows your wishes to make health care decision for you if you are unable to speak for yourself in an emergency or medical event?

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* 5. If you have an Advance Directive where do you keep it?

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* 6. Has the TakeCHARGE Campaign influenced your thoughts or behavior about advance directives? Please rate on a scale of 1-10 with 10 being strongly influenced.

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* 7. Comments