Form 1 OPA PSC Survey English

OMB No.: 0906–0004-REVISION

Expiration date: XX/XX/202X

Public Burden Statement: As the contractor for the C.W. Bill Young Cell Transplantation Program (CWBYCTP) Office of Patient Advocacy (OPA), the National Marrow Donor Program (NMDP) is required to conduct surveys to evaluate satisfaction with the services provided. NMDP will elicit feedback from patients, caregivers, and family members who had contact with the NMDP/Be The Match® Patient Support Center for services, education, and support regarding marrow and umbilical cord blood transplantation. Results of this survey will be used to develop programs and inform resource allocation. The OMB control number for this information collection is 0906–0004-REVISION and it is valid until XX/XX/202X. This information collection is voluntary. Collection of this information fully complies with the Guidelines of 5 CFR 1320.5 Public reporting burden for this collection of information is estimated to average 0.17 hours per response (10 minutes), 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].

1. Overall, how would you rate your experience with the Be The Match Patient Support Center?
   
   ❒ Very good
   ❒ Good
   ❒ Neutral
   ❒ Poor
   ❒ Very poor

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

2. For the following statements please select from “Strongly agree” to “Strongly disagree.” If a statement does not apply to you, please select “NA.”

As a result of the Patient Support Center, I feel…

	Strongly agree	Agree	Neither agree or disagree	Disagree	Strongly disagree	N/A
More confident in my ability to cope with treatment
More hopeful
Less alone
More aware of resources
More informed about treatment options
My questions were answered

Additional comments: __________________________________________________________

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

[open]

4. 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 at all likely Extremely likely

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

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

5. Which best describes you?

❒ Patient

❒ Main caregiver

❒ Family member (who is not the main caregiver)

❒ Friend (who is not the main caregiver)

❒ Not listed, please specify: ________________________

5. Gender:

❒ Male

❒ Female

❒ Not listed, please specify: ________________________________________________

❒ Prefer not to answer

5. Age (in years):

❒ 0-13

❒ 14-18

❒ 19-23

❒ 24-30

❒ 31-40

❒ 41-50

❒ 51-64

❒ 65 or above

❒ Prefer not to answer

5. Your Ethnicity:

❒ Hispanic or Latino

❒ Not Hispanic or Latino

❒ Prefer not to answer

5. 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

10. Highest level of education:

❒ High School

❒ Associate

❒ Undergraduate or Bachelor’s

❒ Graduate or Doctoral

❒ Not listed, please specify: _________________________

❒ Prefer not to answer

11. 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

We thank you for your time spent taking this survey. Your response has been recorded.