SHIP Counseling Survey

Page 1 of 3

Hello, I am trying to reach {insert respondent’s name}. Is {insert he/she} available?

Hi, {insert respondent’s name}. My name is {insert phone-bank caller’s name} and I am calling to ask some 

questions about your experience with the State Health Insurance Assistance Program, or SHIP. You may know 

this program as {insert SHIP/Agency name}.

1. Our records indicate that you spoke with {insert Counselor’s name}, a Counselor from {insert

SHIP/Agency name}, in the last several weeks to discuss Medicare. Is this correct?

a) Yes (go to #2)

b) No (go to #1a)

1a. Do you recall any interaction with someone from {insert SHIP/Agency name}?

a) Yes (go to #1b)

b) No (end the survey)

1b. What was the main focus of your discussion?

a) [open-ended] (read remainder of intro then go to #2)

{insert SHIP/Agency name} would like to learn more about the level of customer service you received, and has 

asked my firm, Coray Gurnitz Consulting, to administer this survey in order to keep your answers completely 

anonymous. We will not reveal your name or other personal identifying information.

This survey collection has been approved by the Office of Management and Budget (OMB) and will expire on 

Dec 31, 2019. If you would like to comment on this survey or confirm that this is a valid collection, please 

contact {insert name(s)} from the Survey Team at {insert contact info}.

2. Would you like to participate in this survey?

a) Yes (go to #3)

b) No (end the survey)

3. Do you have any questions for me before we begin the survey?

a) [open-ended] (read instruction to survey respondent then go to #4)

[Instruction to survey respondent] For many of the questions in this survey, I will ask you to respond to a 

statement. For each statement, you can answer Strongly Agree, Agree, Neither Agree Nor Disagree, Disagree, or 

Strongly Disagree. I will read these five choices after each question, but if you know your answer before I finish 

the list feel free to interrupt me and provide your answer.

4. “I was able to find and contact {insert SHIP/Agency name} in a timely fashion.” Do you . . . ?

a) Strongly Agree (go to #5)

b) Agree (go to #5)

c) Neither Agree nor Disagree (go to #5)

d) Disagree (go to #5)

e) Strongly Disagree (go to #5)

OMB. No. 0985-xxxx

Exp. Date xx/xx/2020
SHIP Counseling Survey

Page 2 of 3

5. Were you able to.... . . ?

a) Speak to someone immediately (go to #6)

b) Asked for contact information so someone could follow up with you later (go to #5a)

5a. How long did it take someone from {insert SHIP/Agency name} to follow-up with you?

a) Same day (go to #6)

b) Within one week (go to #6)

c) Within two weeks (go to #6)

d) Other (please specify ______________) (go to #6)

6. “The information provided to me was accurate.” Do you . . . ?

a) Strongly Agree (go to #7)

b) Agree (go to #7)

c) Neither Agree nor Disagree (go to #7)

d) Disagree (go to #7)

e) Strongly Disagree (go to #7)

7. “{insert SHIP/Agency name} provided me with useful information.” Do you . . . ?

a) Strongly Agree (go to #8)

b) Agree (go to #8)

c) Neither Agree nor Disagree (go to #8)

d) Disagree (go to #7a)

e) Strongly Disagree (go to #7a)

7a. Please complete the following statement: “The information I received was not useful because: . . .”

a) I didn’t receive the information in time to use it (go to #9)

b) I didn’t trust the accuracy of the information I received (go to #8)

c) I couldn’t obtain answers to my questions (go to #8)

d) Other (please specify__________________) (go to #8)

8. As a result of the information you received from counseling, did you take or do you plan to take action?

a) Yes (go to #9)

b) No (go to #9)

c) Don’t know/Not sure (go to #9)

9. “Overall, I was satisfied with my interaction with {insert SHIP/Agency name}.” Do you . . . ?

a) Strongly Agree (go to #10)

b) Agree (go to #10)

c) Neither Agree nor Disagree (go to #10)

d) Disagree (go to #10)

e) Strongly Disagree (go to #10)
SHIP Counseling Survey

Page 3 of 3

10. “I would contact {insert SHIP/Agency name} again for assistance.” Do you . . . ?

a) Strongly Agree (go to #11)

b) Agree (go to #11)

c) Neither Agree nor Disagree (go to #11)

d) Disagree (go to #11)

e) Strongly Disagree (go to #11)

11. “I would recommend {insert SHIP/Agency name}’s service to others.” Do you . . . ?

a) Strongly Agree (go to #12)

b) Agree (go to #12)

c) Neither Agree nor Disagree (go to #12)

d) Disagree (go to #12)

e) Strongly Disagree (go to #12)

[Instruction to survey respondent] The next question is the final survey question. This question doesn’t have an 

answer scale, so please provide any thoughts you may have.

12. What could {insert SHIP/Agency name} do to improve the service(s) they provided to you?

a) [open-ended] (end survey)