Context.-Although measures exist that assess patient engagement in the advance care planning (ACP) process, there are no validated tools to assess surrogate decision-makers' (SDM) role in ACP. Objectives.-To adapt and begin to validate a patient-oriented questionnaire for use with SDMs of patients with chronic illness Methods.-Questions from the 55-item patient-oriented ACP engagement survey were adapted for SDMs and assessed for face validity. The resultant 47-item questionnaire was administered to 65 SDMs of patient with chronic illness. Responses were assessed and items were flagged for removal based on item redundancy, nonresponses, and ceiling effects. A preliminary exploratory factor analysis was performed, internal consistency assessed, and domains constructed based on findings. Results.-The 47-item questionnaire was administered to 65 participants (mean age 51.8; 81% female; 96% Caucasian). 17 items were removed due to redundancy (r>0.80), 13 items lacking face validity were removed. In preliminary exploratory factor analysis of the resultant 17-item questionnaire, a 3-factor solution was deemed most statistically and conceptually sound. Items were organized into domains: 1) serving as a SDM (7-items); 2) contemplation (4-items); 3) Readiness (6-items). Internal consistency for each domain was high (Cronbach alpha 0.90-0.91).