Post-Treatment Navigator Evaluation Form

Your feedback is important to us, so thank you for taking the time to fill out this form.

 
Question - Not Required - Do you feel the Post-Treatment Navigator and its contents helped you to better understand what to expect physically after treatment?





 
Question - Not Required - Do you feel the Post-Treatment Navigator and its contents helped you to better understand what to expect emotionally after treatment?





 
Question - Not Required - I found the Post-Treatment Navigator easy to understand.





 
Question - Not Required - After receiving the Post-Treatment Navigator, I am more aware of resources available to me.





 
Question - Not Required - How did you receive your post-treatment navigator?






 

(Maximum response 255 chars, approx. 5 rows of text)
 
Question - Not Required - When did you receive your Post-Treatment Navigator?




 
Question - Not Required - Please check which sections of the Post-Treatment Navigator you are using or plan to use.
Please make at least 1 selection from the choices below.

 
Question - Not Required - Which part of the Post-Treatment Navigator do you find most useful?
Please make at least 1 selection from the choices below.

 
Question - Not Required - Would you recommend the Post-Treatment Navigator to another breast cancer survivor?





 

(Maximum response 255 chars, approx. 5 rows of text)
  Optional: Please tell us a little about yourself!
   


   


   


   


 
Question - Not Required - Please describe the place you live.



 
Question - Not Required - With what stage of breast cancer were you diagnosed?





 


 
Question - Not Required - Your treatments include(d) (choose all that apply):
Please make at least 1 selection from the choices below.

 

(Maximum response 255 chars, approx. 5 rows of text)
 
Question - Not Required - With what ethnic/racial group do you most closely identify?






 

(Maximum response 255 chars, approx. 5 rows of text)
 
Question - Not Required - What level of education have you completed?





 


 
Question - Not Required - What type of insurance do you have?






 

(Maximum response 255 chars, approx. 5 rows of text)
 
Question - Not Required - Please provide your current employment status:






 

(Maximum response 255 chars, approx. 5 rows of text)
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