Download Session 10 Survivor Questionnaires

!Vida! Breast Cancer Education For Survivors, Families & Caregivers and Providers Via Telemedicine
Session 10 BCS: Movement for Breast Cancer Survivors
Date: ________________________
Location: __________________________
General Information Survey
BEFORE VIEWING THE SESSION, PLEASE COMPLETE THIS SURVEY
Instructions: Please circle the correct answer/s:
1- I attended this session:
In-person
Via Videoconference
Via internet
DVD/ VHS
2- I am a (please circle all that apply):
Breast cancer survivor (anyone with a diagnosis of breast cancer)
Relative of a breast cancer survivor
Lay health worker/ promoter
Caregiver of a breast cancer survivor
CPG (Community Partner Group member –assisted in project development)
Health care provider (please specify) _______________________________________
Other ______________________
3- My place of residence is in the following city/town/ rural area_______________
4- My health insurance is:
Private (please specify) (HMO/ PPO) _______________________________________
AHCCCS
Other________________________________________________________________
No health insurance
5- The following describe me: Age __________
6- I describe my ethnicity as:
Hispanic
7- I describe my race as:
American Indian
Pacific Islander
Asian
African American
Gender ______________
Non-Hispanic
White
Other (please specify) ________
8- The highest grade of school that I completed is __________________________
9- At home, I speak:
English only
English and Spanish
Spanish only
Other (please specify) _____________________________
10- I needed this presentation translated into Spanish.
11- I prefer the English to Spanish translation to be:
Written
Spoken
I have no preference
Yes
No
Not applicable to me
12- How did you hear about this session? ________________________________
13- Did you attend a session before? No
Yes
If yes, this is my #1, #2, #3, #4, #5, #6, #7, #8, #9, #10 sessions attended
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!Vida! Breast Cancer Education For Survivors, Families & Caregivers and Providers Via Telemedicine
¡Vida! Pre-Assessment Survey
BEFORE VIEWING THE SESSION, PLEASE COMPLETE THIS SURVEY
Session 10 BCS: Movement for Breast Cancer Survivors
Please read the following questions and provide the best answer:
1. My knowledge about this topic is: (circle only one answer)
none at all
very little
somewhat
a lot
2. Movement and Physical Activity:
a. Is discouraged during breast cancer treatments
b. should be limited to one time a week during cancer treatments
c. Can actually help reduce side effects of treatments such as fatigue and
nausea
d. causes stress on the body during cancer treatments
3. Weight gain
a. does not affect risk of breast cancer occurrence or recurrence
b. is common after a diagnosis of breast cancer
c. does not affect body image or self-esteem
d. only occurs in women with cancer
4. Which of the following is NOT considered moderate exercise?
a. swimming
b. yoga
c. running at full speed
d. dance
5. Dance/movement therapy:
a. is a proven effective treatment modality
b. is only for people who know how to dance
c. teaches people how to dance
d. is used only with children
6. Research studies show that the minimum amount of physical activity recommended
to prevent breast cancer recurrence is:
a. 30 minutes a week
b. 4-5 hours a week
c. 1-3 hours a week
d. 1 hour a day
PLEASE DO NOT COMPLETE ANY ADDITIONAL FORMS
UNTIL AFTER YOU HAVE VIEWED THE ENTIRE PRESENTATION
Vida! Session Packet for all Participants
PLEASE KEEP ALL FORMS TOGETHER
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!Vida! Breast Cancer Education For Survivors, Families & Caregivers and Providers Via Telemedicine
PLEASE PROCEED AND VIEW
THE VIDA! PRESENTATION
Educational Objectives for this Session
1.-Discuss the role of movement in the prevention of breast cancer onset
2-Outline the appropriate role of movement for breast cancer survivors
3-Define the role of movement in the breast cancer recurrence prevention
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!Vida! Breast Cancer Education For Survivors, Families & Caregivers and Providers Via Telemedicine
Session Satisfaction Survey
AFTER VIEWING THE SESSION, PLEASE COMPLETE THIS SURVEY
STRONGLY
DISAGREE
DISAGREE
NO
OPINION
AGREE
STRONGLY
AGREE
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9- I was comfortable with the
camera and other equipment.
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10- I was able to hear questions
from the other locations.
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1- Videoconferencing, DVD/ VHS,
attending via internet made my
attendance possible
2 -I was able to speak freely and
ask questions.
3- I learned new information.
4- The teaching techniques were
conducive to learning.
5- The information presented was
appropriate for my needs.
6- The handouts were useful for
the session.
7- The educational objectives were
met.
8- The speaker was prepared and
informative.
11- I had no trouble hearing the
presenter.
12- I could see the presenter
clearly during the session.
13- My experience was as good as
seeing the speaker face to face.
14- The English-Spanish
translation did not distract me from
the content of the presentation.
15- The English to Spanish
translation did not make the
session too long.
16- Overall, I am satisfied with this
training.
17- What other topics would you like to see addressed?
Comments:
The information you have provided will help to increase our body of knowledge
about how well this educational session has met your needs and expectations
Vida! Session Packet for all Participants
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!Vida! Breast Cancer Education For Survivors, Families & Caregivers and Providers Via Telemedicine
¡Vida! Post-Assessment Survey
AFTER VIEWING THE SESSION, PLEASE COMPLETE THIS SURVEY
Session 10 BCS: Movement for Breast Cancer Survivors
Please read the following questions and provide the best answer:
1. After viewing this presentation, my knowledge about this topic is: (circle the best
answer)
none at all
very little
somewhat
a lot
2. Movement and Physical Activity:
a. Is discouraged during breast cancer treatments
b. should be limited to one time a week during cancer treatments
c. Can actually help reduce side effects of treatments such as fatigue and
nausea
d. causes stress on the body during cancer treatments
3. Weight gain
a. does not affect risk of breast cancer occurrence or recurrence
b. is common after a diagnosis of breast cancer
c. does not affect body image or self-esteem
d. only occurs in women with cancer
4. Which of the following is NOT considered moderate exercise?
a. swimming
b. yoga
c. running at full speed
d. dance
5. Dance/movement therapy:
a. is a proven effective treatment modality
b. is only for people who know how to dance
c. teaches people how to dance
d. is used only with children
6. Research studies show that the minimum amount of physical activity recommended
to prevent breast cancer recurrence is:
a. 30 minutes a week
b. 4-5 hours a week
c. 1-3 hours a week
d. 1 hour a day
Vida! Session Packet for all Participants
PLEASE KEEP ALL FORMS TOGETHER
5
!Vida! Breast Cancer Education For Survivors, Families & Caregivers and Providers Via Telemedicine
Thank you very much for taking the time to complete all study forms
You may submit the completed forms in any of the following ways:
Via fax: (520) 626-2225 ATTN: Angela Valencia
Via mail: Arizona Cancer Center
ATTN: Angela Valencia
1515 N. Campbell Ave
Tucson, AZ 85724
or
Via e-mail to: [email protected]
If you have any questions please call:
Bettina Hofacre at (520) 626-3265
Vida! Session Packet for all Participants
PLEASE KEEP ALL FORMS TOGETHER
6