Form 1 E C 1 E C Survey - Be The Match CLEAN

OMB No. 0906-0004 Exp. XX/XX/202X

Be The Match^® Patient Support Center Survey

Instructions: You were recently in contact (by phone or email) with Be The Match® Patient Support Center. Please take 5 minutes to complete this survey. Your feedback will help us improve our programs and services for future patients and families.

Participating in this survey is voluntary. Your responses are confidential. If you have questions about the survey, please contact us at 1-888-999-6743 or email [email protected].

1. Overall, how would you rate your experience with Be The Match Patient Support Center?

❒ Very good ❒ Good ❒ Neutral ❒ Poor ❒ Very poor

Please tell us why you chose the rating you selected: ________________________________

For the following questions please select from 5 for “Strongly agree” to 1 for “Strongly disagree.” If a statement does not apply to you, please select 0 for “N/A.”

As a result of the Patient Support Center I feel…	Strongly agree	Agree	Neutral	Disagree	Strongly disagree	N/A
More confident in my ability to cope with treatment	5	4	3	2	1	0
More hopeful	5	4	3	2	1	0

Less alone	5	4	3	2	1	0
More aware of resources	5	4	3	2	1	0
More informed about treatment options	5	4	3	2	1	0
My questions were answered	5	4	3	2	1	0

Additional comments: __________________________________________________________________

2. What challenges are you facing that Be The Match could not help with, if any?

[open]

3. On a scale of 0 to 10, how likely are you to recommend Be The Match Patient Support Center to someone else in your situation?

0 1 2 3 4 5 6 7 8 9 10

Not likely to recommend Extremely likely to Recommend

Please tell us why you chose the rating you selected: ________________________________

4. Be The Match wants to share anonymous comments from this survey for promotional materials. Would you be willing to have your comments shared anonymously for public purposes?

❒ Yes

❒ No

Please tell us about yourself. Your responses help us create resources that meet your unique needs. All answers are confidential.

5. Your gender:

❒ Male

❒ Female

❒ Not listed, please specify: ____________________________

❒ Prefer not to answer

6.Your age (in years):

❒ 18 or under ❒ 41-50

❒ 19-23 ❒ 51-64

❒ 24-30 ❒ 65 or above

❒ 31-40 ❒ Prefer not to answer

7. Your race Select all that apply.

❒ American Indian or Alaska Native            

❒ Asian                                                               

❒ Black or African American                          

       ❒ Native Hawaiian or Other Pacific Islander

❒ White              

❒ Not listed, please specify: ____________________________ 

❒ Prefer not to answer

8. Your ethnicity

                 ❒ Hispanic or Latino                                      

                 ❒ Not Hispanic or Latino   

❒ Prefer not to answer   

9. Your highest level of education:

❒ High school ❒ Graduate or Doctoral

❒ Associate ❒ Not listed, please describe: ___________________

❒ Undergraduate/Bachelor’s ❒ Prefer not to answer

10. Which best describes you?

❒ Patient ❒ Family member (who isn’t the main caregiver)

❒ Main caregiver ❒ Friend (who is not the main caregiver)

❒ Not listed, please specify: _________________________________________________

Thank you for taking this survey. Your feedback helps us make our programs and services as useful as possible.

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

Be The Match® Patient Support Center

500 N. 5th Street

Minneapolis, MN 55401-1206

Questions? Contact us at:

Toll free: 1-888-999-6743

Email: [email protected]

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-0004 and it is valid until XX/XX/202X. This information collection is voluntary. Public reporting burden for this collection of information is estimated to average .167 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].