{"id":7239,"date":"2021-02-24T08:50:10","date_gmt":"2021-02-24T14:50:10","guid":{"rendered":"https:\/\/uamscaregiving.org\/springdale\/?page_id=7239"},"modified":"2026-02-06T13:35:25","modified_gmt":"2026-02-06T19:35:25","slug":"pre-medicare-basics-survey","status":"publish","type":"page","link":"https:\/\/uamscaregiving.org\/springdale\/pre-medicare-basics-survey\/","title":{"rendered":"Pre-Medicare Basics Survey"},"content":{"rendered":"<p>Please take a moment to fill out this brief survey to help ensure that we are providing valuable programs to our community.<\/p>\n<p>By completing the survey you help us to continue to offer these programs at no cost to you.<\/p>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_97' >\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_97'  action='\/springdale\/wp-json\/wp\/v2\/pages\/7239' data-formid='97' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_97' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_97_23\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_97_23\" ><label class='gfield_label gform-field-label' for='input_97_23'>What is today&#039;s date?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_97_23'><strong><i>(MM\/DD\/YYYY)<\/i><\/strong><\/div><div class='ginput_container ginput_container_date'>\n                            <input aria-describedby='field_97_23_dmessage' name='input_23' id='input_97_23' type='text' value='04\/25\/2026' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_97_23_date_format gfield_description_97_23\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_97_23_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_97_23' class='gform_hidden' value='https:\/\/uamscaregiving.org\/springdale\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_97_18\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_97_18\" ><label class='gfield_label gform-field-label' for='input_97_18'>Enter your birthday<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/label><div class='gfield_description' id='gfield_description_97_18'><strong><i>(MM\/DD\/YYYY)<\/i><\/strong><\/div><div class='ginput_container ginput_container_date'>\n                            <input aria-describedby='field_97_18_dmessage' name='input_18' id='input_97_18' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_97_18_date_format gfield_description_97_18\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_97_18_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_97_18' class='gform_hidden' value='https:\/\/uamscaregiving.org\/springdale\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_97_41\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_97_41\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_97_41'>\n                            \n                            <span id='input_97_41_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_41.3' id='input_97_41_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_97_41_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_97_41_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_41.6' id='input_97_41_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_97_41_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><\/fieldset><div id=\"field_97_46\" class=\"gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_97_46\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_97_46'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_46' id='input_97_46' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_97_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_97_25\" ><legend class='gfield_label gform-field-label' >How would you rate your overall knowledge of Medicare?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_97_25'>\n\t\t\t<div class='gchoice gchoice_97_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Excellent'  id='choice_97_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_25_0' id='label_97_25_0' class='gform-field-label gform-field-label--type-inline'>Excellent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_97_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Good'  id='choice_97_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_25_1' id='label_97_25_1' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_97_25_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Fair'  id='choice_97_25_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_25_2' id='label_97_25_2' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_97_25_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Poor'  id='choice_97_25_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_25_3' id='label_97_25_3' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><fieldset id=\"field_97_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_97_26\" ><legend class='gfield_label gform-field-label' >How would you rate your understanding of what the various parts of Medicare cover?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_97_26'>\n\t\t\t<div class='gchoice gchoice_97_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Excellent'  id='choice_97_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_26_0' id='label_97_26_0' class='gform-field-label gform-field-label--type-inline'>Excellent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_97_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Good'  id='choice_97_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_26_1' id='label_97_26_1' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_97_26_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Fair'  id='choice_97_26_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_26_2' id='label_97_26_2' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_97_26_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Poor'  id='choice_97_26_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_26_3' id='label_97_26_3' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><fieldset id=\"field_97_27\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_97_27\" ><legend class='gfield_label gform-field-label' >How would you rate your understanding of the costs associated with Medicare enrollment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_97_27'>\n\t\t\t<div class='gchoice gchoice_97_27_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Excellent'  id='choice_97_27_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_27_0' id='label_97_27_0' class='gform-field-label gform-field-label--type-inline'>Excellent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_97_27_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Good'  id='choice_97_27_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_27_1' id='label_97_27_1' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_97_27_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Fair'  id='choice_97_27_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_27_2' id='label_97_27_2' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_97_27_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_27' type='radio' value='Poor'  id='choice_97_27_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_27_3' id='label_97_27_3' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><fieldset id=\"field_97_30\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_97_30\" ><legend class='gfield_label gform-field-label' >How would you rate your knowledge of how to access resources to help with Medicare planning and questions?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_97_30'>\n\t\t\t<div class='gchoice gchoice_97_30_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Excellent'  id='choice_97_30_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_30_0' id='label_97_30_0' class='gform-field-label gform-field-label--type-inline'>Excellent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_97_30_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Good'  id='choice_97_30_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_30_1' id='label_97_30_1' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_97_30_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Fair'  id='choice_97_30_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_30_2' id='label_97_30_2' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_97_30_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_30' type='radio' value='Poor'  id='choice_97_30_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_30_3' id='label_97_30_3' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><fieldset id=\"field_97_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_97_44\" ><legend class='gfield_label gform-field-label' >How would you rate your confidence in choosing a Medicare plan that works for you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_97_44'>\n\t\t\t<div class='gchoice gchoice_97_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Excellent'  id='choice_97_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_44_0' id='label_97_44_0' class='gform-field-label gform-field-label--type-inline'>Excellent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_97_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Good'  id='choice_97_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_44_1' id='label_97_44_1' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_97_44_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Fair'  id='choice_97_44_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_44_2' id='label_97_44_2' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_97_44_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Poor'  id='choice_97_44_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_97_44_3' id='label_97_44_3' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/fieldset><fieldset id=\"field_97_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_97_43\" ><legend class='gfield_label gform-field-label' >We would like to follow up with you in 30-45 days after your participation in this program.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\"> * <span class='sr-only'> Required<\/span><\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_97_43'><i>Remember that your approval helps us to ensure that our programs are of value to our community.<\/i> <\/div><div class='ginput_container 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