Form 1 OPA PSC Survey English

Be the Match® Patient Services Survey

05122023 - OPA PSC Survey English - Burden Statement - OMB 0906-0004

Patient Services Survey

OMB: 0906-0004

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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: ______________________________


  1. 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: __________________________________________________________



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


[open]


  1. 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.

  1. 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: ________________________

  1. Gender:

Male

Female

Not listed, please specify: ________________________________________________

Prefer not to answer


  1. Age (in years):

0-13

14-18

19-23

24-30

31-40

41-50

51-64

65 or above

Prefer not to answer



  1. Your Ethnicity:

Hispanic or Latino

Not Hispanic or Latino

Prefer not to answer


  1. 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



  1. Highest level of education:

High School

Associate

Undergraduate or Bachelor’s

Graduate or Doctoral

Not listed, please specify: _________________________

Prefer not to answer



  1. 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.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorPaxton Huberty
File Modified0000-00-00
File Created2023-07-29

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