Bag It Bag Feedback Form 2022

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Your responses to this survey will be used to help us make the Bag It bag as useful as possible. In addition, our funders require us to provide them with data about who we serve and measure how effective the bag is.

We'd love feedback from both survivors and caregivers. If there is someone else in your circle who used the Bag It bag, please share this link with them.

Providing your name and email will allow us to enter you into our quarterly drawing for a gift card. You will be entered 1 time in the quarter your feedback was received.

*Please note Bag It will not share your contact information with other organizations.

I am the: *

Survivor/Patient

Caregiver

Other:

The contents of the Bag It bag helped me be more organized. *

Yes

Required

Please explain your answer:

The contents of the Bag It bag helped me cope better/worry less. *

Yes

Required

Please explain your answer:

The contents of the Bag It bag helped me feel more confident and comfortable speaking up for myself and asking questions of my healthcare team. *

Yes

Required

Please explain your answer:

Please mark the number from 1 (not at all helpful) to 5 (extremely helpful) that shows how helpful each booklet has been for you. *

1 Not at all helpful

2 Somewhat helpful

3 Helpful

4 Very helpful

5 Extremely helpful

I do not remember this booklet

Caring for the Caregiver

Heal Well

Paths to Survivorship

Taking Time

If you could add/change one thing in the bag what would it be?

Comments or anything you would like to share:

Today's Date

YYYY

Date of diagnosis

YYYY

Facility

First Name *

Last Name

Phone #

Mailing address

City *

State *

Zip Code

You may use my responses: *

with my name

without my name

May we contact you for follow-up information? (Additional feedback, a written or video testimonial, as a potential speaker/story) *

Yes

Did you receive a cancer type specific bag? *

CLL

Hope for Stomach Cancer

Lung

Metastatic Breast Cancer

MPN

Uterine

No, I did not

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms