LGFB Workshop Participant Evaluation
RequiredRequired Question(s)

Look Good...Feel Better (LGFB) workshops are designed to help women cope with the appearance side effects of cancer treatment.  To help us serve you better, please complete this brief questionnaire.  The information you provide will be used as we continually enhance the LGFB program.
 
Required 1.

How did you hear about LGFB?
Medical professional (doctor, nurse, social worker)
Friend or relative
Media (magazine ad, television, radio
Local American Cancer Society office
Web site (LGFB or other Web site)
Hairdresser (or stylist)
Another patient
The LGFB toll-free number
Other  
Required 2.

How satisfied were you with the LGFB program overall?
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
  • Comment:

  • 500 characters left.
Required 3.

How would you rate the value of this program in improving your self-image?
Very Useful
Useful
Of Little Use
Not Useful
n/a
  • Comment:

  • 500 characters left.
Required 4.

Would you recommend LGFB to other cancer patients?
Yes
No
  • Comment:

  • 500 characters left.
5.

How satisfied were you with the following?
 Very Satisfied Satisfied Neither Satisfied nor Dissatisfied Dissatisfied Very Dissatisfied N/A 
Your ability to find and access the workshop
Ease of registration for the workshop
Organization of the workshop
Group format of the workshop
Knowledge of the beauty professional volunteers
Professionalism of the beauty professional volunteers
Complimentary makeup kit
LGFB patient instruction booklet
Required 6.

Were the following subject areas covered during your workshop?
 Yes No    
Skin Care    
Makeup    
Wigs    
Head Coverings    
Nail Care    
  • Comment:

  • 500 characters left.
Required 7.

Please rate the usefulness of the information provided in the LGFB workshop regarding the following:
 Very Useful Useful Of Little Use Not Useful N/A 
Skin Care
Makeup
Wigs
Head Coverings
Nail Care
  • Comment:

  • 500 characters left.
Required 8.

What is your five-digit zip code?
 

50 characters left.
Required 9.

In what state did you attend the LGFB workshop?
 

50 characters left.
Required 10.

In what city did you attend the LGFB workshop?
 

50 characters left.
11.

At which type of facility was the program held?
Hospital
Cancer Center
American Cancer Society Office
Other  
12.

On what date did you attend the LGFB workshop?  Month:
January
February
March
April
May
June
July
August
September
October
November
December
13.

On which day of the month did you attend the LGFB workshop?
 

50 characters left.
Required 14.

Please select your age range:
18 - 29
30 - 39
40 - 49
50 - 59
60 - 69
70 - 79
80 - 89
Prefer not to answer
Required 15.

What is your ethnic background?
African American/Black
American Indian/Alaskan Native
Asian
Chicana or Mexican-American
Other Hispanic/Latina
Caucasian/White
Native Hawaiin or other Pacific Islander
Prefer not to answer
16.

For what type of cancer are you being treated?
Brain & Other Nervous System
Breast
Colon & Rectum
Hodgkin's Disease
Leukemia
Lung
Lymphoma
Melanoma of the Skin
Multiple Myeloma
Ovarian
Pancreas
Uterine or Endometrial
Other  
17.


Have you participated in any other programs or services offered by the American Cancer Society?
Reach to Recovery
I Can Cope
tlc catalog
Road to Recovery
Cancer Survivor's Network
Other  


Thank you for taking the time to complete this evaluation.  The information you provide will not be given or sold to any other organization.  Look Good...Feel Better is offered through the collaborative efforts of the Personal Care Products Council Foundation, the American Cancer Society, and the Professional Beauty Association|National Cosmetology Association.
 
18.

(OPTIONAL)  Please enter the information indicated below.

By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

First Name:
Last Name:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

19.

Would you like to receive information regarding future LGFB activities?
Yes
No
20.

Additional comments:
 

350 characters left.
21.

FOR NCIC USE ONLY:  Please enter code:
 

50 characters left.