Take Charge! Programs Survey
Are you a South Country Health Alliance member?
*
Yes
No
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What Be Rewarded Preventive and Well-Care Reward Vouchers have you completed in the last 6 months? (select all that apply)
Prenatal Care Voucher
Postpartum Care Voucher
Infant Checkups Voucher
Well-child Visit Voucher
Child & Adolescent Well-care Visit Voucher
Childhood Immunizations Voucher
Immunization for Adolescents Voucher
Lead Test Voucher
Chlamydia Testing Voucher
Preventive Dental Care Voucher
Colorectal Cancer Screening Voucher
Breast Cancer Screening Voucher
Cervical Cancer Screening Voucher
None of these
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How satisfied are you with South Country's Be Rewarded incentive voucher program?
Very Satisfied
Satisfied
Neither Satisfied or Dissatisfied
Dissatisfied
Very Dissatisfied
N/A
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What helped you decide to complete the preventive care service?
Information about the benefits of preventive care services when I first enrolled.
The health care information included on the preventive care voucher.
The South Country mailings reminding me that I or my child may be eligible for the service.
My or my child's health care provider (doctor, nurse, etc.) encouraging me to complete the service.
The dollar amount of the gift card from South Country for completing the service.
Reading about the reward programs in the Connection member newsletter.
A public health nurse encouraged me to complete the service.
The service is covered by my or my child's health insurance.
The chance to receive a gift card from South Country for receiving the service.
The importance of wellness and staying healthy.
Other, please explain.
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Where do you get your information about health and wellness services?
My health care provider (doctor, nurse, etc.)
County public health (WIC clinic, public health nurse, etc.)
South Country Health Alliance website
Family or friends
My care coordinator
South Country Health Alliance member materials (Member Handbook, Take Charge! Brochure, etc.)
South Country Health Alliance Facebook page
Other, please explain
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How likely would you have completed the preventive care service if the reward had not been offered?
Very Likely
Likely
Neither Likely nor Unlikely
Unlikely
Very Unlikely
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Do you have suggestions for improving the South Country reward program?
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Do you have access to the internet?
Yes
No
If yes, please check all ways that you access the internet?
Personal computer/tablet
Computer/tablet at work
Computer/tablet of friend or family
Computer at public library
Personal cell phone
Work cell phone
Cell phone of a friend or family
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What is your preference for receiving health and wellness information from us? Check all that may apply.
Email
Postal mail
Text message
Phone call
No preference
I have no interest in receiving health and wellness information from South Country.
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Would you be interested in participating in a member advisory forum/committee to give us feedback?
Yes
No
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What would be the best way for us to hold meetings to get feedback?
Virtual meeting on the computer/phone
In-person meeting in your community
Hybrid meeting (combination of virtual and in-person)
Other, please explain
What is the best time to hold a meeting?
Morning (8 a.m. to noon)
Afternoon (Noon to 6 p.m.)
Evening (After 6 p.m.)
What health care topics are you curious about that would be good to discuss at a member advisory meeting?
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Any other thoughts you would like to share?
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