1. Please take a moment to give us your feedback

Please take a moment to answer the following questions about the Decisions. Support. Possibilities. Transplant as an Option When You Are 50 and Older DVD and booklet. We would like to know how you used these materials and if they helped you better understand marrow and cord blood transplants.

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* 1. Who in your family watched the DVD? (Check all that apply)

Select from "Very helpful" to "Very unhelpful" or "N/A" (Not Applicable) for questions 2 and 3:

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* 2. After watching the DVD, did it help you better understand:

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The medical risks of transplant?
The financial impact of transplant?
The social impact of transplant on your family?
Some of the responsibilities of the caregiver?

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* 3. After reading through the booklet, did it help you:

  Very Helpful Somewhat Helpful Neutral Somewhat Unhelpful Very Unhelpful N/A
Talk to your family about treatment options?
Understand the possible complications and side effects of transplant?
Understand which questions to ask your doctor?
Know which questions to ask about your insurance coverage?
Plan your next steps if you decide to move forward with a transplant?

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* 4. Did the stories and advice from other patients aged 50 and older in the DVD make an impact on your treatment decision?

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* 5. Overall, how would you rate Decisions. Support. Possibilities?

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* 6. Would you recommend the Office of Patient Advocacy (OPA) to others in your situation?

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* 7. Patient is:

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* 8. Patient’s age:

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* 9. Patient's ethnicity:

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* 10. Patient's race: (Check all that apply)

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* 11. Patient's highest level of education:

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* 12. Additional Comments or Suggestions: (Note: If you would like to receive feedback from us, please include your contact information.)

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