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202X ACL Evaluation

Start of Block: Intro and Demographics

Introduction 

Please complete the following evaluation to let us know about your experience at the 202X 

SMP/SHIP/MIPPA National Conference, which took place July 25‒28, 202X.

This evaluation can be completed on a mobile device or a desktop/laptop computer.

Q1 Including this conference, how many SMP or SHIP National Conferences have you 

attended?

o This is my first (1) 

o2–4 (2) 

o5–9 (3) 

o10 or more (4) 

Q2 My work relates to the following OHIC Programs:

(Select all that apply)

▢ SMP (1) 

▢ SHIP (2) 

▢ MIPPA (3) 

▢ Other (Please Specify) (4) 

________________________________________________
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Q3 My role is:

(Select all that apply)

▢ SHIP Director (1) 

▢ SMP Director (2) 

▢ MIPPA Director (3) 

▢ Coordinator (4) 

▢ Program Staff (5) 

▢ Other (Please Specify) (6) 

________________________________________________

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Q4 How long have you been in this role?

oLess than 1 year (1) 

o1 - 3 years (2) 

o3 - 5 years (3) 

o More than 5 years (4) 

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Q5 Please rate these aspects of the overall conference:

Extremely 

satisfied 

(5)

Somewhat 

satisfied 

(4)

Neither 

satisfied 

nor 

dissatisfied 

(3)

Somewhat 

dissatisfied 

(2)

Extremely 

dissatisfied 

(1)

Virtual Platform: Zoom 

Meetings (ex: 

instructions, ease of 

access) (Q5_1) 

o o o o o

Conference and ACL 

staff (ex: 

knowledgeable/helpful) 

(Q5_2) 

o o o o o

Conference materials 

provided (ex: 

clarity/helpfulness) 

(Q5_3) 

o o o o o

Overall conference 

experience (Q5_4) o o o o o

End of Block: Intro and Demographics

Start of Block: Days Attended

Q6 Which of the following day(s) did you attend? Select all that apply.

▢ Day 1, July 25th (1) 

▢ Day 2, July 26th (2) 

▢ Day 3, July 27th (3) 

▢ Day 4, July 28th (4) 

End of Block: Days Attended

Start of Block: Day 1
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Day 1 Day 1

Please answer the following questions about the sessions from Day 1, Monday, July 25th.

Q1.1 Overall I was satisfied with the presentations and activities from Day 1. 

o Strongly agree (5) 

o Somewhat agree (4) 

o Neither agree nor disagree (3) 

o Somewhat disagree (2) 

o Strongly disagree (1) 

Q1.1b If you attended the Center-Led Social Session: Who are We? (Optional) on Day 1, 

please rate your level of satisfaction.

o Extremely satisfied (5) 

o Somewhat satisfied (4) 

o Neither satisfied or dissatisfied (3) 

o Somewhat satisfied (2) 

o Extremely dissatisfied (1) 

o Did not attend (99) 
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Q1.2 For the Future of Medicare plenary session, please rate your level of agreement with the 

following statements about the session:

Strongly 

agree (5)

Somewhat 

agree (4)

Neither 

agree or

disagree 

(3)

Somewhat 

disagree 

(2)

Strongly 

disagree 

(1)

Did not 

attend 

(99)

Provided 

useful 

information I 

can use in my 

day-to-day 

responsibilities 

(1) 

o o o o o o

Was 

presented at a 

level 

appropriate to 

my experience 

(2) 

o o o o o o

Speakers were 

knowledgeable 

and had good 

presentation 

skills (3) 

o o o o o o

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Q1.3 Please select which breakout session you attended for Day 1.

oIntegrated Care: Resources, Challenges, and Lessons Learned (1) 

o Home Health/Hospice Coverage and Fraud (2) 

o What Do You Know About SMP Complex Interactions? (3) 

o Welcome to Medicare Lessons Learned (4) 

oI did not attend a breakout session on Day 1 (5) 

Skip To: End of Block If Please select which breakout session you attended for Day 1. = 5

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Q1.4 For the breakout session, ${Q1.3/ChoiceGroup/SelectedChoices}, please rate your level of 

agreement with the following statements about the session:

Strongly 

agree (5)

Somewhat 

agree (4)

Neither 

agree nor 

disagree 

(3)

Somewhat 

disagree 

(2)

Strongly 

disagree 

(1)

Did not 

attend 

(99)

Provided 

useful 

information I 

can use in my 

day-to-day 

responsibilities 

(1) 

o o o o o o

Was 

presented at a 

level 

appropriate to 

my experience 

(2) 

o o o o o o

Speakers were 

knowledgeable 

and had good 

presentation 

skills (3) 

o o o o o o

End of Block: Day 1

Start of Block: Day 2

Day 2 Day 2

Please answer the following questions about the sessions from Day 2, Tuesday, July 26th.
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Q2.1 Overall I was satisfied with the presentations and activities from Day 2. 

o Strongly agree (5) 

o Somewhat agree (4) 

o Neither agree nor disagree (3) 

o Somewhat disagree (2) 

o Strongly disagree (1) 

Q2.2 If you attended the Chair Yoga Activity Session (Optional), please rate your level of 

satisfaction.

o Extremely satisfied (5) 

o Somewhat satisfied (4) 

o Neither satisfied nor dissatisfied (3) 

o Somewhat dissatisfied (2) 

o Extremely dissatisfied (1) 

o Did not attend (99) 

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Q2.3 For the Advancing Equity in Support for Underserved Communities Through ACL 

Programs plenary session, please rate your level of agreement with the following statements 

about the session:

Strongly 

agree (5)

Somewhat 

agree (4)

Neither 

agree nor 

disagree 

(3)

Somewhat 

disagree 

(2)

Strongly 

disagree 

(1)

Did not 

attend 

(99)

Provided 

useful 

information I 

can use in my 

day-to-day 

responsibilities 

(1) 

o o o o o o

Was 

presented at a 

level 

appropriate to 

my experience 

(2) 

o o o o o o

Speakers were 

knowledgeable 

and had good 

presentation 

skills (3) 

o o o o o o

Page Break
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Q2.4 Please select which Regional Breakout session you attended for Day 2

o Region 1 — CT, MA, ME, NH, RI, VT (1) 

o Region 2 — NY, NJ, PR, VI (2) 

o Region 3 — DC, DE, MD, PA, VA, WV (3) 

o Region 4 — AL, FL, GA, KY, MS, NC, SC, TN (4) 

o Region 5 — IL, IN, MI, MN, OH, WI (5) 

o Region 6 — AR, LA, OK, NM, TX (6) 

o Region 7— IA, KS, MO, NE (7) 

o Region 8 — CO, MT, UT, WY, ND, SD (8) 

o Region 9 — CA, NV, AZ, HI, GU (9) 

o Region 10 — AK, ID, OR, WA (10) 

oI did not attend a breakout session on Day 2 (99) 

Skip To: End of Block If Please select which Regional Breakout session you attended for Day 2 = 99

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Q2.5 For the breakout session, ${Q2.4/ChoiceGroup/SelectedChoices}, please rate your level 

of agreement with the following statements about the session:

Strongly 

agree (5)

Somewhat 

agree (4)

Neither 

agree nor 

disagree 

(3)

Somewhat 

disagree 

(2)

Strongly 

disagree 

(1)

Did not 

attend 

(99)

Provided 

useful 

information I 

can use in my 

day-to-day 

responsibilities 

(1) 

o o o o o o

Was 

presented at a 

level 

appropriate to 

my experience 

(2) 

o o o o o o

End of Block: Day 2

Start of Block: Day 3

Day 3 Day 3

Please answer the following questions about the sessions from Day 3, Wednesday, July 27th.
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Q3.1 Overall I was satisfied with the presentations and activities from Day 3. 

o Strongly agree (5) 

o Somewhat agree (4) 

o Neither agree nor disagree (3) 

o Somewhat disagree (2) 

o Strongly disagree (1) 

Q3.1b If you attended the Center-Led Social Session: Living Your Best Life (Optional) on 

Day 3, please rate your level of satisfaction.

o Extremely satisfied (5) 

o Somewhat satisfied (4) 

o Neither satisfied or dissatisfied (3) 

o Somewhat satisfied (2) 

o Extremely dissatisfied (1) 

o Did not attend (99) 

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Q3.2 Please select which breakout session you attended for Day 3.

oLong-Term Care Insurance Updates (1) 

o Telehealth Benefits and Vulnerabilities to Medicare (2) 

o Medicare Beneficiary Ombudsman Updates (4) 

o Can Medicare Help Promote Economic Security for Seniors? An Overview of New NonMedical Benefits in Medicare Advantage (6) 

oI did not attend a breakout session on Day 3 (5) 

Skip To: Q3.4 If Please select which breakout session you attended for Day 3. = 5

Page Break
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Q3.3 For the breakout session, ${Q3.2/ChoiceGroup/SelectedChoices}, please rate your level 

of agreement with the following statements about the session:

Strongly 

agree (5)

Somewhat 

agree (4)

Neither 

agree nor 

disagree 

(3)

Somewhat 

disagree 

(2)

Strongly 

disagree 

(1)

Did not 

attend 

(99)

Provided 

useful 

information I 

can use in my 

day-to-day 

responsibilities 

(1) 

o o o o o o

Was 

discussed at a 

level 

appropriate to 

my experience 

(2)

o o o o o o

Speakers were 

knowledgeable 

and had good 

presentation 

skills (4) 

o o o o o o
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Q3.4 For the State of the Programs and What's to Come plenary session, please rate your 

level of agreement with the following statements about the session:

Strongly 

agree (5)

Somewhat 

agree (4)

Neither 

agree nor 

disagree 

(3)

Somewhat 

disagree 

(2)

Strongly 

disagree 

(1)

Did not 

attend 

(99)

Provided 

useful 

information I 

can use in my 

day-to-day 

responsibilities 

(1) 

o o o o o o

Was 

presented at a 

level 

appropriate to 

my experience 

(2) 

o o o o o o

Speakers were 

knowledgeable 

and had good 

presentation 

skills (3) 

o o o o o o

End of Block: Day 3

Start of Block: Day 4

Day 4 Day 4

Please answer the following questions about the sessions from Day 4, Thursday, July 28th.
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Q4.1 Overall I was satisfied with the presentations and activities from Day 4. 

o Strongly agree (5) 

o Somewhat agree (4) 

o Neither agree nor disagree (3) 

o Somewhat disagree (2) 

o Strongly disagree (1) 

Q4.1b If you attended the Center-Led Social Session: SHIP/SMP/MIPPA Trivia (Optional) on 

Day 3, please rate your level of satisfaction.

o Extremely satisfied (5) 

o Somewhat satisfied (4) 

o Neither satisfied or dissatisfied (3) 

o Somewhat satisfied (2) 

o Extremely dissatisfied (1) 

o Did not attend (99) 

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Q4.2 Please select which breakout session you attended for Day 4.

oImportant Protections for Older Adults: Medial Debt and Imposter Scams (1) 

o Medicare Savings Programs: Trends and Opportunities for Boosting Enrollment (2) 

o STARS Updates (4) 

oIntegrated Care: Impacts of research findings and new models on SMP, SHIP, and 

MIPPA services) (6) 

oI did not attend a breakout session on Day 4 (5) 

Skip To: Q4.4 If Please select which breakout session you attended for Day 4. = 5

Page Break
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Q4.3 For the breakout session, ${Q4.2/ChoiceGroup/SelectedChoices}, please rate your level 

of agreement with the following statements about the session:

Strongly 

agree (5)

Somewhat 

agree (4)

Neither 

agree nor 

disagree 

(3)

Somewhat 

disagree 

(2)

Strongly 

disagree 

(1)

Did not 

attend 

(99)

Provided 

useful 

information I 

can use in my 

day-to-day 

responsibilities 

(1) 

o o o o o o

Was 

discussed at a 

level 

appropriate to 

my experience 

(2) 

o o o o o o

Speakers were 

knowledgeable 

and had good 

presentation 

skills (4) 

o o o o o o

Page Break
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Q4.4 For the Federal Partner Updates plenary session, please rate your level of agreement 

with the following statements about the session:

Strongly 

agree (5)

Somewhat 

agree (4)

Neither 

agree nor 

disagree 

(3)

Somewhat 

disagree 

(2)

Strongly 

disagree 

(1)

Did not 

attend 

(99)

Provided 

useful 

information I 

can use in my 

day-to-day 

responsibilities 

(1) 

o o o o o o

Was 

presented at a 

level 

appropriate to 

my experience 

(2) 

o o o o o o

Speakers were 

knowledgeable 

and had good 

presentation 

skills (3) 

o o o o o o

End of Block: Day 4

Start of Block: Conclusion

Q7 What did you appreciate about this year’s conference?

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________
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Q8 Do you have any suggestions that you believe would help improve future conferences?

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

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Q9 What topics would you like to see covered at future conferences?

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Q10 What else would you like to tell us about the conference overall?

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

End of Block: Conclusion

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