Workshop Evaluation 2019

Question Title

* 1. I attended as a:

Question Title

* 2. What is your race/ethnicity? (Check all that apply)

Question Title

* 3. Which of the following ethnicity categories best describes you?

Question Title

* 4. How old are you

Question Title

* 5. What is your gender identity?

Question Title

* 6. What is the highest level of education you have completed?

Question Title

* 7. Which of the following best describes the area you live in?

Question Title

* 8. How knowledgeable were you about Chronic Lymphocytic Leukemia (CLL) BEFORE this workshop?

Question Title

* 9. How knowledgeable were you about Chronic Lymphocytic Leukemia (CLL) AFTER this workshop?

Question Title

* 10. As a result of this workshop:

  Strongly Disagree Disagree Neutral Agree Strongly Agree
I feel a greater sense of control over dealing with and managing side effects of cancer treatment.
I understand that there are specific steps that can be taken to manage fatigue.
I am confident I can ask my health care team questions about side effects of cancer and its treatment.
I feel better prepare to emotionally cope with this cancer experience.

Question Title

* 11. I would recommend this workshop to others with cancer and their loved ones.

Question Title

* 12. I have experienced emotional distress due to my/ my loved one’s cancer.

Question Title

* 13. The social and emotional effects of cancer, and their impact on my life, have been adequately addressed by my healthcare team.

Question Title

* 14. Today, how concerned are you about...?

  Not at all Slightly Moderately Seriously Very Seriously
Feeling sad or depressed.
Feeling nervous or afraid.
Worrying about the future and what lies ahead.
Feeling lonely or isolated.

Question Title

* 15. Where do you turn to seek information about cancer? (Check all that apply)

Question Title

* 16. Do you currently participate in a support group?

Question Title

* 17. If you have cancer/cancer survivor, what was your primary cancer diagnosis?

Question Title

* 18. Do you have metastatic/advanced cancer?

Question Title

* 19. How long has it been since you were first diagnosed with cancer?

Question Title

* 20. What kind of treatment are you receiving/have received in the past?

Question Title

* 21. When you were first diagnosed, how involved were you in choosing a specific course or type of treatment?

Question Title

* 22. Please select the statement(s) BEST describing why you chose the treatment you did. (Check all that apply)

Question Title

* 23. Have you experienced any of the following side effects from treatment/ cancer itself? (Check all that apply)

Question Title

* 24. General comments or suggestions about the workshop (i.e. are there other topics not covered in this workshop that you would be interested in, etc.):

Please consider joining the Cancer Experience Registry at www.CancerExperienceRegistry.org/joing/GCquadcities

It is a place where you can share your voice and learn from others while helping shape new programs, research and policy for those living with cancer.

If you would like to receive additional information on the Registry or on the educational materials we offer, please provide your first name and e-mail address.

Question Title

* 25. First Name

Question Title

* 26. Email

Thank you for your feedback!

T