Dads in Action Survey

Dear Dad in the Bleeding Disorders community,

NYCHC is launching a new program called Dads in Action in cooperation with the Hemophilia Federation of America. From the HFA Website: “Dads in Action is an educational and social support system designed to create a network of Dads in the bleeding disorders community who educate, support and challenge each other as they strive to be proactive and responsible male role models for their children and families. Program participants include both fathers of children who have a bleeding disorder and fathers with hemophilia or other bleeding disorders.”

If you are either a father of someone with a bleeding disorder or a father who has a bleeding disorder, we invite you to complete this short survey to help us create programs that will be interesting an engaging for community members. If you do not fit one of these categories but know someone who does, please forward this to them. All surveys must be completed by September 7th.

As a special thank you for participating, you will be invited at the end of the survey to enter your name into a drawing to win a $50 gift certificate to Target.

Question Title

* 1. Please enter your contact information (required if you want to be included in the drawing; otherwise optional):

Name:

Address:

Address 2:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

Question Title

* 2. Which of the following best describes you?

Father of someone with hemophilia or other bleeding disorder

Father who has hemophilia or other bleeding disorder

Question Title

* 3. Where do you or your child receive treatment (please enter name of Hemophilia Treatment Center or hospital)?

Question Title

* 4. Please rate the following topics according to your level of interest with a number between 1 and 5, 5 being very interested and 1 being not interested at all:

	5	4	3	2	1
Research and treatment advances in bleeding disorders	Research and treatment advances in bleeding disorders 5	Research and treatment advances in bleeding disorders 4	Research and treatment advances in bleeding disorders 3	Research and treatment advances in bleeding disorders 2	Research and treatment advances in bleeding disorders 1
Caring for my child with a bleeding disorder	Caring for my child with a bleeding disorder 5	Caring for my child with a bleeding disorder 4	Caring for my child with a bleeding disorder 3	Caring for my child with a bleeding disorder 2	Caring for my child with a bleeding disorder 1
Self or home infusion skills	Self or home infusion skills 5	Self or home infusion skills 4	Self or home infusion skills 3	Self or home infusion skills 2	Self or home infusion skills 1
Sports, exercise and joint health for people with bleeding disorders	Sports, exercise and joint health for people with bleeding disorders 5	Sports, exercise and joint health for people with bleeding disorders 4	Sports, exercise and joint health for people with bleeding disorders 3	Sports, exercise and joint health for people with bleeding disorders 2	Sports, exercise and joint health for people with bleeding disorders 1
Life stages and transitions with bleeding disorders	Life stages and transitions with bleeding disorders 5	Life stages and transitions with bleeding disorders 4	Life stages and transitions with bleeding disorders 3	Life stages and transitions with bleeding disorders 2	Life stages and transitions with bleeding disorders 1
Family relationships and bleeding disorders	Family relationships and bleeding disorders 5	Family relationships and bleeding disorders 4	Family relationships and bleeding disorders 3	Family relationships and bleeding disorders 2	Family relationships and bleeding disorders 1

Question Title

* 5. Which of the following activities do you enjoy (rate each between 1 and 5, 5 being enjoy very much and 1 being don’t enjoy at all):

	5	4	3	2	1
Attending live sporting events	Attending live sporting events 5	Attending live sporting events 4	Attending live sporting events 3	Attending live sporting events 2	Attending live sporting events 1
Participating in sports and recreation	Participating in sports and recreation 5	Participating in sports and recreation 4	Participating in sports and recreation 3	Participating in sports and recreation 2	Participating in sports and recreation 1
Going to restaurants or bars	Going to restaurants or bars 5	Going to restaurants or bars 4	Going to restaurants or bars 3	Going to restaurants or bars 2	Going to restaurants or bars 1
Playing cards or other games	Playing cards or other games 5	Playing cards or other games 4	Playing cards or other games 3	Playing cards or other games 2	Playing cards or other games 1
Live music or cultural events	Live music or cultural events 5	Live music or cultural events 4	Live music or cultural events 3	Live music or cultural events 2	Live music or cultural events 1
Discussion Groups	Discussion Groups 5	Discussion Groups 4	Discussion Groups 3	Discussion Groups 2	Discussion Groups 1

Other activities that you enjoy:

Question Title

* 6. We are looking at hosting our first event in October. How likely do you think you would be to attend this first event (please rate your likelihood of attending between 1 and 5, 5 being very likely and 1 being not very likely)?

Question Title

* 7. Which of the following days/times would work for you (please check all that apply)?

Saturday daytime

Saturday evening

Sunday daytime

Sunday evening

Monday evening

Tuesday evening

Wednesday evening

Thursday evening

Friday evening

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* 8. Is there anything else you would like us to know about your interests?

Question Title

* 9. Thank you for completing the survey. Stay tuned for an invitation to our first Dads in Action event in the near future.

Would you like to be entered into a drawing to win a $50 giftcard for Target?

Yes

Question Title

* 1. Please enter your contact information (required if you want to be included in the drawing; otherwise optional):

Question Title

* 2. Which of the following best describes you?

Question Title

* 3. Where do you or your child receive treatment (please enter name of Hemophilia Treatment Center or hospital)?

Question Title

* 4. Please rate the following topics according to your level of interest with a number between 1 and 5, 5 being very interested and 1 being not interested at all:

Question Title

* 5. Which of the following activities do you enjoy (rate each between 1 and 5, 5 being enjoy very much and 1 being don’t enjoy at all):

Question Title

* 6. We are looking at hosting our first event in October. How likely do you think you would be to attend this first event (please rate your likelihood of attending between 1 and 5, 5 being very likely and 1 being not very likely)?

Question Title

* 7. Which of the following days/times would work for you (please check all that apply)?

Question Title

* 8. Is there anything else you would like us to know about your interests?

Question Title

* 9. Thank you for completing the survey. Stay tuned for an invitation to our first Dads in Action event in the near future.Would you like to be entered into a drawing to win a $50 giftcard for Target?

* 9. Thank you for completing the survey. Stay tuned for an invitation to our first Dads in Action event in the near future.

Would you like to be entered into a drawing to win a $50 giftcard for Target?