Form cover

Page 1 of 2

Kansas Health P260207

Please provide us with your First and Last Name

Please provide us with your email address.

Which of the following statements best describes who in your household is responsible for healthcare decisions for you and/or your family?

Which of the following statements best describes who in your household is responsible for healthcare decisions for you and/or your family?

A

I am the person most responsible

B

I share responsibility with someone else

C

Someone else is most responsible

D

Prefer not to answer

E

Don’t know / not sure

Thinking about healthcare systems or healthcare providers in your area, how familiar would you say you are with each of the following?

	Aware and Familiar	Aware, Not Familiar	Not Aware
The University of Kansas Health System
AmberMed-Sheridan County Hospital
Cheyenne County Hospital
Decatur Health
Gove County Medical Center
Graham County Hospital
Lane County Hospital
Logan County Health Services
Norton County Hospital
Rawlins County Health Center
Scott County Hospital
Trego County-Lemke Memorial Hospital
Wichita County Health Center

And thinking about your primary healthcare services provider, are they affiliated with any of the options below?

Not taking into account travel distance or time, are there any healthcare systems or healthcare providers that you would flatly reject going to if you were given the choice?