Form 1 Patient Services Survey

Be The Match^® Patient Services Survey

Instructions: You were recently in contact with Be The Match® Patient Services. Please take 10 minutes to complete this survey and let us know how helpful we were to you. All responses are confidential.

Your feedback helps us make our programs as useful as possible for transplant patients and caregivers.

1. What topics did you request information on? Check all that apply.

❒ Caregiver

❒ Clinical trials

❒ Diseases

❒ Financial and insurance issues

❒ Hospital life

❒ How a donor match is found

❒ Life after transplant (survivorship)

❒ Other treatment options (other than transplant)

❒ Peer support (talk to a transplant patient, survivor or caregiver)

❒ Risks and benefits of transplant

❒ Transplant centers

❒ Other; please describe: ________________________________________________________

2. Overall, how would rate your contact with Be The Match® Patient Services? Check one.

❒ Very Good ❒ Good ❒ Neutral ❒ Poor ❒ Very Poor

Please explain: ________________________________________________________________

We’d like to know how helpful we were during your contact. Please tell us how much you agree or disagree with the following statements: Select from 5 for ‘Strongly agree’ to 1 for ‘Strongly disagree’

We were…	Strongly agree	Agree	Neutral	Disagree	Strongly disagree	N/A
Able to answer your questions.	5	4	3	2	1	0
Please explain:
Easy to understand.	5	4	3	2	1	0
Please explain:

We’d also like to know how you felt after our contact. Please tell us how much you agree or disagree with each of the following statements: Select from 5 for ‘Strongly agree’ to 1 for ‘Strongly disagree’

After our contact, I …	Strongly agree	Agree	Neutral	Disagree	Strongly disagree	N/A
Felt more prepared to talk with the medical team about transplant.	5	4	3	2	1	0
Please explain:
Felt more aware of resources that might be helpful to me.	5	4	3	2	1	0
Please explain:
Didn’t have to wait long for follow-up information.	5	4	3	2	1	0
Please explain:

8. What follow-up actions, if any, did you take after your contact with us?

9. Would you recommend Be The Match Patient Services to someone else in your situation?

❒ Yes ❒ Maybe ❒ No ❒ Don’t know

Please explain: ____________________________________________________________

10. Is there anything else you’d like to tell us?

Please tell us who you are. We’d like to know who filled out this survey. Your responses help us create resources that meet your unique needs. All answers will be kept confidential.

12. You are:

❒ Male ❒ Female

13. Which best describes you:

❒ Transplant patient

❒ Main caregiver

❒ Family member (who is not the main caregiver)

❒ Friend (who is not the main caregiver)

❒ Other, please specify: _________________________

14. Your age (in years):

❒ 0-13

❒ 14-18

❒ 19-23

❒ 24-30

❒ 31-40

❒ 41-50

❒ 51-64

❒ 65 and above

15. Your ethnicity:

❒ Hispanic or Latino ❒ Not Hispanic or Latino ❒ Decline to answer

16. Your race: Check one.

❒ American Indian or Alaska Native

❒ Asian

❒ Black or African American

❒ Native Hawaiian or Other Pacific Islander

❒ White

❒ Other, please specify: _______________________

❒ Don’t know ❒ Decline to answer

17. Your highest level of education:

❒ High school

❒ Associate

❒ Undergraduate or Bachelors

❒ Graduate or Doctoral

❒ Other, please specify: __________________________________________

Thank you!

Your feedback helps us make our programs as useful as possible for transplant patients and caregivers.

Please return the survey in the enclosed pre-paid envelope or mail to:

Be The Match Patient Services National Marrow Donor Program 3001 Broadway Street NE, Suite 100 Minneapolis, MN 55413

You may contact us at: Toll free: 1-888-999-6743 [email protected]

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