1. What brought you to the CHIP site today? Select... I was looking for information for myself I was looking for health care information for someone else I'm a community partner/agency and was looking for information to help someone apply/enroll I was just browsing Other If other, what?
2. How did you learn about CHIP? Select... Browsing the internet/search engine From a friend/family member/co-worker From my current health provider From county assistance office or community agency From a brochure/ad (TV or radio) Other If other, what?
3. How often do you visit this website? Select... First visit Once a month Once a week Every day Other If other, how often?
4. Which information/resources were you looking for?
5. Which area(s) of the website do you find most useful?
6. Was there something you were looking for, but couldn't find? No Yes If yes, what?
7. Was anything hard to find? No Yes If yes, what?
8. Please answer the following questions:
9. How can CHIP improve this site for you?
1. What is your age in years? Under 18 years of age 18-24 years old 25-34 years old 35-49 years old 50-64 years old 65+ years of age
2. What is your age gender? Male Female
3. I have: Select... No children 1 child 2 children 3 children 4 children 5 or more children
4. Which of the following best describes your race/ethnicity? Select... Asian & Pacific Islander Black Hispanic / Latino White
5. What language do you speak at home? Select... English Only Mostly Non-English - Some English Mostly English -Some Non-English Non-English Only
6. What is your marital status? Single Married Divorced
7. Are you a PA resident? No Yes If yes, in which county do you live? Select... ADAMSALLEGHENYARMSTRONGBEAVERBEDFORDBERKSBLAIRBRADFORDBUCKSBUTLERCAMBRIACAMERONCARBONCENTRECHESTERCLARIONCLEARFIELDCLINTONCOLUMBIACRAWFORDCUMBERLANDDAUPHINDELAWAREELKERIEFAYETTEFORESTFRANKLINFULTONGREENEHUNTINGDONINDIANAJEFFERSONJUNIATALACKAWANNALANCASTERLAWRENCELEBANONLEHIGHLUZERNELYCOMINGMCKEANMERCERMIFFLINMONROEMONTGOMERYMONTOURNORTHAMPTONNORTHUMBERLANDPERRYPHILADELPHIAPIKEPOTTERSCHUYLKILLSNYDERSOMERSETSULLIVANSUSQUEHANNATIOGAUNIONVENANGOWARRENWASHINGTONWAYNEWESTMORELANDWYOMINGYORK
8. What is your approximate annual household income (before taxes)? Select... Less than $24k $25k to $49k $50k to $74k $75k to $99k $100k to $149k $150k or more
9. What is your highest level of education? Select... Some high school High school diploma or GED Technical or trade school diploma Some college Associate degree Bachelors' degree Masters' Degree or some other post-professional degree
