The code block below illustrates how one might use # and // as comments in your logic and calculations.

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Required format:

K9cyL9tvpDAPLKnhqTiDe3L8U6zFyqLZ

Welcome to Living Well

Thank you for choosing to participate in our Living Well Self-Management Program. Please review the consent form, and initial acknowledgement. In addition to your consent we require your first and last name, and address to participate in the program. Completing the program evaluation is helpful, but not required to participate in the program itself.

Living Well Consent and Release

I understand that by initialing below, I am consenting to have my survey data shared with others. The Living Well program is responsible for keeping my data stored securely in locked file cabinets or secured databases in accordance to HIPAA guidelines.

I understand that my name and any other identifying information will be removed from any data that is shared with program partners, funding sources, or used in publications and presentations.

For further information and to ask any questions, please feel free to contact the Living Well office at 607-547-3948 or email livingwellsessions@bassett.org

Further, by initialing below, I absolve and release the Mary Imogene Bassett Hospital (d/b/a Bassett Medical Center) as well as the program license holder, New York State Office for the Aging (NYSOFA) and their officers, employees, and agents from any liability for any personal injury or other concern arising out of or in any way connected with my participation in this self-management workshop.

My initials act as my signature for this consent form.

* must provide value

First Name

* must provide value

Last Name

* must provide value

Street Address

* must provide value

City

* must provide value

State

* must provide value

Zip Code

* must provide value

How was this survey completed?

Living Well Team Member Entering Data - Initials

Date data entered

M-D-Y

In-person Workshop?

Yes

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What is your phone number?

What is your email address?
(required for some program materials)

Please select the workshop you'd like to register for:

* must provide value

Select your preferred method of participation:

* must provide value

In-person small group

Mailed tool kit with small group phone support

Mailed tool kit independent study

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Select your preferred method of participation:

* must provide value

Mailed tool kit with small group phone support

Mailed tool kit independent study

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Select your preferred method of participation:

* must provide value

Mailed tool kit with small group phone support

Mailed tool kit independent study

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Date Toolkit Mailed

M-D-Y

What is your Date of Birth?

M-D-Y

What is your gender?

Are you of Hispanic, Latino, or Spanish origin?

What is your race? (Please check all that apply)

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other

Race - other (description)

What is the highest level of education that you have completed?

Do you live alone?

Yes

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Are you a caregiver?

Yes

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Has a health care provider ever told you that you have any of the following chronic conditions?

Chronic Obstructive Pulmonary Disease (COPD), Emphysema, or Chronic bronchitis

Asthma

Alzheimer's or Related Dementia

Arthritis/Rheumatic Disease

Breathing/Lung Disease

Cancer or Cancer Survivor

Chronic Pain

COVID-19 long-haul

Depression or Anxiety Disorders

Diabetes

Heart Disease

High Cholesterol

Hypertension

Multiple Sclerosis

Osteoporosis

Pre-Diabetes

Stroke

Other Chronic Condition

None (No Chronic Condition)

Conditions - other (description)

Number of years since cancer diagnosis:

Currently in cancer treatment?

Yes

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Years since treatment completed:

How did you learn about this workshop?

How has the pandemic affected your ability to manage your chronic condition(s)?

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.