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Annual Pregnant by Choice Benefit Awareness and Satisfaction Survey Questions: 1. Please tell us your name (first and last).

2. If you would like to receive email communications from the Wyoming Department of Health about the Pregnant by Choice Program, please provide your email address below. (If not, leave this question blank.)

3. Have you used your Pregnant by Choice (PBC) benefits in the last 12 months?

Yes ➔ Please skip to Question 3 below

No ➔ Continue to Question 2 4. If you have not used your PBC benefits, please tell us the reasons why you have not used the services. (Check all that apply)

My usual provider is not part of PBC/would not accept PBC payment

Could not find health care provider

Could not get an appointment

Appointment days and times were not convenient

Health care provider location was not convenient

Health care provider didn’t offer service(s) I needed

I can take care of my health without PBC services

I was concerned about how much it would cost me

I did not have time to go, did not have transportation to get there, or did not have child care

If there was another reason or you have other feedback about why you didn’t use your PBC benefits (please explain)

5. For each of the Pregnant by Choice (PBC) services listed below, please mark the response that best fits your experience. Please mark one box in each row.