Bag It Bag Feedback Form 2019
YOUR FEEDBACK IS IMPORTANT to help BAG IT continue to inform and empower those impacted by cancer. Your responses to this survey will be used to help us understand the value of the BAG IT bag.
Bag It will not share your contact information with any organization.
I am the:
Caregiver
Patient
Other:
The contents of the BAG IT bag/guidebook helped me/my caregiver be more organized.
Patient - yes
Patient - no
Caregiver - yes
Caregiver - no
Please explain your answer:
Your answer
The contents of the BAG IT bag/guidebook helped me/caregiver become more knowledgeable about advocating for myself? cancer survivorship?. (become more confident/comfortable in being part of my healthcare team? Speaking up for myself? Asking questions? Quality of life?
yes for patient
no for patient
yes for caregiver
no for caregiver
Please explain your answer:
Your answer
The contents of the BAG IT bag/guidebook helped me/caregiver cope better/worry less.
yes for patient
no for patient
yes for caregiver
no for caregiver
Please explain your answer:
Your answer
If you could add/change one thing in the bag what would it be?
Your answer
Please mark the number that shows how helpful each publication has been for you/caregiver:
Caring for the Caregiver
Heal Well
Paths to Survivorship
Taking Time
1 -not at all helpful
2
3
4
5 - extremely helpful
I do not remember this publication
Caring for the Caregiver
Heal Well
Paths to Survivorship
Taking Time
1 -not at all helpful
2
3
4
5 - extremely helpful
I do not remember this publication
Comments or anything you would like to share:
Your answer
You may use my comments
with my name
without my name
May we contact you for follow-up information?
Yes
No
Maybe
Today's Date
MM
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DD
/
YYYY
Date of diagnosis
MM
/
DD
/
YYYY
Name
Your answer
Email
Your answer
Phone #
Your answer
Mailing address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
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