Instrument and Letters

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

❒ Life after transplant (survivorship)

❒ Clinical trials

❒ Other treatment options (other than
transplant)

❒ Diseases

❒ Peer support (talk to a transplant patient,

❒ Financial and insurance issues

survivor or caregiver)

❒ Hospital life

❒ Risks and benefits of transplant

❒ How a donor match is found

❒ 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…
3. Able to answer your questions.

Strongly
agree

Agree

Neutral

Disagree

Strongly
disagree

N/A

5

4

3

2

1

0

5

4

3

2

1

0

Please explain:
4. Easy to understand.
Please explain:

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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

5

4

3

2

1

0

5

4

3

2

1

0

5

4

3

2

1

0

5. Felt more prepared to talk with the
medical team about transplant.
Please explain:
6. Felt more aware of resources that
might be helpful to me.
Please explain:
7. Didn’t have to wait long for followup information.
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
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❒ Female
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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

❒ 31-40

❒ 14-18

❒ 41-50

❒ 19-23

❒ 51-64

❒ 24-30

❒ 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

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❒ Decline to answer

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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]

__-M__-Q__-FY__-CY__
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Dear [Name]:
We invite you to tell us about your recent contact with us, Be The Match®. Please take
5-10 minutes to complete this survey.
Your participation is voluntary and we will do our best to keep your responses
confidential. We will never link your answers to your name, email, mailing address, or
other personal information. Your participation will not affect any medical treatments or
services you may be receiving.
 If you prefer not to complete the survey, please leave the survey blank and return
it in the pre-paid envelope.
If you have any questions about the survey, please contact Heather Moore at 888-9996743, ext. 8328 (toll-free direct) or [email protected]
If you’d like to speak to a Patient Services Coordinator for information and support,
please call our toll free number at 1-888-999-6743.
Si desea ayuda para traducir esta información, puede llamar a 1-888-999-6743.
Your feedback matters! With your input, we can make our patient, family and
caregiver resources as helpful as possible.
Sincerely,

Kate Pederson, MSW, LICSW
Senior Manager, Patient and Health Professional Services
Phone: (612) 627-8126 toll free: 1 (888) 999-6743 x 7523
Email: [email protected]

Dear [Name]:
We sent you a survey about 2 weeks ago inviting you to tell us about your contact with
us, Be The Match®. We’d still like to hear from you. Please take 5-10 minutes to
complete the enclosed survey.
Your participation is voluntary and we will do our best to keep your responses
confidential. We will never link your answers to your name, email, mailing address, or
other personal information. Your participation will not affect any medical treatments or
services you may be receiving.
 If you prefer not to complete the survey, please leave the survey blank and return
it in the pre-paid envelope.
If you have any questions about the survey, please contact Heather Moore at 888-9996743, ext. 8328 (toll-free direct) or [email protected]
If you’d like to speak to a Patient Services Coordinator for information and support,
please call our toll free number at 1-888-999-6743.
Si desea ayuda para traducir esta información, puede llamar a 1-888-999-6743.
Your feedback matters! With your input, we can make our patient, family and
caregiver resources as helpful as possible.
Sincerely,

Kate Pederson, MSW, LICSW
Senior Manager, Patient and Health Professional Services
Phone: (612) 627-8126 toll free: 1 (888) 999-6743 x 7523
Email: [email protected]