Kokua Mau Advance Care Planning Materials Survey

Dear Kokua Mau
In an effort to better serve our community, we continue to identify resource materials for people facing serious illness, their loved ones and professionals. We’d like you help in identifying good materials that you already use and gaps that we could fill, either by creating new materials or finding other resources. Could you please take a few minutes to complete this survey to help us with our process.

Many thanks – Kokua Mau Advance Care Planning Committee

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* 1. Do you provide educational materials to people with serious illness and their loved ones? If so, what are they? Where are they from? Are they available to share and/or purchase from original owner? Please give us as much information as possible. Please note that the answer boxes expand and only appear to be short for better readability.

a. Pain management

b. Pain Management for Cancer

c. Depression

d. Anxiety

e. Dementia

f. Other

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* 2. Are there also educational materials on the same topic that you share with the professionals? If so, what are they? What are the materials? Where are they from? Is it available to share and/or purchase from original owner? Please give us as much information as possible.

a. Pain management

b. Pain Management for Cancer

c. Depression

d. Anxiety

e. Dementia

f. Other

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* 3. If you have made your own education material/pamphlets, would you or organization be willing to share with Kokua Mau? Please provide details

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* 4. Which websites do you access to provide information for patients and loved ones?

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* 5. As a professional, which websites do you use?

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* 6. Have you translated materials in other languages? If so, what have you already done and would you be willing to share?

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* 7. What materials in different languages would be useful to you? (The materials listed are already available in English on the Kokua Mau website.) Please be specific about languages that would be useful.

Advance Directive Booklet

Advance Directive Form

POLST Frequently Asked Questions for Consumer

POLST Form

Tube Feeding

Questions about CPR

Others

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* 8. What is missing from what Kokua Mau currently provides? Please indicate topic and the type of information you’d like i.e. website, short handout, video, etc.

a. Pain management

b. Pain Management for Cancer

c. Depression

d. Anxiety

e. Decision Making

f. Dementia

g. Other

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* 9. Please give us your contact information.

Name:

Company:

Email Address:

Phone Number: