Patient Resources/Tools Feedback Form Survey

1. Patient Resources/Tools Feedback Form

Please take a few minutes to complete this survey on the patient resources and/or tools you used. We welcome your feedback and appreciate your honesty on our materials, and would like to hear from you about what other patient materials you would like to see.

1. Which patient resource or tool are you providing feedback on?

Which patient resource or tool are you providing feedback on?

2. Please rate the tool or resource you selected on the following:

	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree	N/A
It provided high-quality information.	*Please rate the tool or resource you selected on the following: It provided high-quality information. Strongly Agree	It provided high-quality information. Agree	It provided high-quality information. Neither Agree nor Disagree	It provided high-quality information. Disagree	It provided high-quality information. Strongly Disagree	It provided high-quality information. N/A
It was easy to understand.	It was easy to understand. Strongly Agree	It was easy to understand. Agree	It was easy to understand. Neither Agree nor Disagree	It was easy to understand. Disagree	It was easy to understand. Strongly Disagree	It was easy to understand. N/A
It answered my questions or providing the desired information.	It answered my questions or providing the desired information. Strongly Agree	It answered my questions or providing the desired information. Agree	It answered my questions or providing the desired information. Neither Agree nor Disagree	It answered my questions or providing the desired information. Disagree	It answered my questions or providing the desired information. Strongly Disagree	It answered my questions or providing the desired information. N/A

3. What questions did you have that were not answered by the resource or tool? What additional information would you have liked to see?

What questions did you have that were not answered by the resource or tool? What additional information would you have liked to see?

4. Would you recommend this resource or tool to someone else?

Would you recommend this resource or tool to someone else? Yes

Comments:

5. On what other topics would you like to see patient resources or tools?

On what other topics would you like to see patient resources or tools?

6. What format(s) do you prefer for patient resources or tools?

What format(s) do you prefer for patient resources or tools? Brochure

Fact sheet

Interactive tool

Wallet card

Electronic resources (web-based)

Printed resources (hard copy)

Other (please specify):

7. Contact information (optional):

Contact information (optional): First name:
Last name:
Email:

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1. Patient Resources/Tools Feedback Form

Patient Resources/Tools Feedback Form
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