top of page

Survey Participant ID

Your Participant Identification is a 4-digit PIN number that you select. It is very important that you keep the same PIN and enter it consistently on each of the surveys. This ID is used only to link your responses while keeping your identity anonymous.

Survey 1: Initial Assessment

Please complete this pre-survey to help us understand your healthcare education needs. Please only do this survey once. Your responses are anonymous, and the ID is used ONLY to link your pre- and post-survey responses. We do not keep or share any personal identifying information.

Your Participant Identification number should be a 4-digit PIN number. It is very important that you keep the same PIN and enter it consistently on each of the surveys. Thank you for participating in this very important DNP project.

How do you feel about your health?
Not confident
Slightly confident
Moderately confident
Very confident
Do you follow your treatment plan daily?
Not confident
Slightly confident
Moderately confident
Very confident
Do you use any tools or systems to monitor or track your health?
Not confident
Slightly confident
Moderately confident
Very confident
How well do you know your chronic condition?
Not confident
Slightly confident
Moderately confident
Very confident
How do you feel about the management of your condition?
Not confident
Slightly confident
Moderately confident
Very confident
How sure are you in making choices about your health?
Not confident
Slightly confident
Moderately confident
Very confident
Are you okay with asking your healthcare providers questions about your condition?
Not confident
Slightly confident
Moderately confident
Very confident
Do you feel confident when you visit or talk with a healthcare provider, either in person or through telehealth?
Not confident
Slightly confident
Moderately confident
Very confident
How sure are you in knowing which signs may need medical care?
Not confident
Slightly confident
Moderately confident
Very confident
Do you feel that you have support (family, friends, community) to help with your health?
Not confident
Slightly confident
Moderately confident
Very confident

Your privacy is important. This survey is anonymous and helps us improve healthcare outcomes through education for our senior community. No personal details like names or addresses are collected.

bottom of page