LGFB Workshop Participant Evaluation
RequiredRequired Question(s)

 

Thank you for attending a Look Good Feel Better (LGFB) workshop. These workshops are designed to help women cope with the appearance side effects of cancer treatment. To help us improve the LGFB program, please complete this brief survey. It should take 5-10 minutes to complete. The information you provide in the survey will not be given or sold to any other organization. Thank you!

 

Your Look Good Feel Better Experience:
 
Required 1.

How would you rate your confidence level before attending the LGFB workshop?

Very Confident
Somewhat Confident
Neutral
Not Very Confident
Not at All Confident
Required 2.

How would you rate your satisfaction level as it relates to what you learned in the LGFB workshop?

Very Satisfied
Somewhat Satisfied
Neutral
Somewhat Dissatisfied
Very Dissatisfied
  • Comment:

  • 500 characters left.
Required 3.

How would you rate the value of this program in improving your self-image?

Very Valuable
Somewhat Valuable
Neutral
Of Little Value
No Value
  • Comment:

  • 500 characters left.
Required 4.

How would you rate your confidence level with your appearance after experiencing the Look Good Feel Better workshop?

Very Confident
Somewhat Confident
Neutral
Not Very Confident
Not at All Confident
Required 5.
Please rate the degree to which you agree or disagree with each of the following statements.
 Strongly Agree Somewhat Agree Neither Agree nor Disagree Somewhat Disagree Strongly Disagree 
I felt supported by the group.
My appearance makes me feel more confident.
I would recommend Look Good Feel Better to other women with cancer.
  • Comment:

  • 500 characters left.
Required 6.

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
Registration process 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 7.

Were the following subject areas covered during your workshop?

 Yes No    
Introductory Video    
Skin Care    
Makeup    
Wigs & Head Coverings    
Nail Care    
LGFB Guide to Personal Style Video    
  • Comment:

  • 500 characters left.
Required 8.

How useful was the information provided in the LGFB workshop on each of these topics?


 Very Useful Useful Of Little Use Not Useful N/A 
Skin Care
Makeup
Wigs
Head Coverings
Nail Care
  • Comment:

  • 500 characters left.
Required 9.

How did you hear about Look Good Feel Better?

Medical professional (doctor, nurse, social worker)
Friend or relative
Media (magazine ad, television, radio)
Local American Cancer Society office
Website (LGFB or other website)
Hairdresser (or stylist)
Another patient
The LGFB toll-free number
Other  

Your LGFB Workshop:
 
Required 10.

What is your five-digit zip code?

 

50 characters left.
Required 11.

In what state did you attend the LGFB workshop? (Please type the full state name.)


 

50 characters left.
Required 12.

In what city did you attend the LGFB workshop?

 

50 characters left.
13.

At which type of facility was the program held?


Community Hospital
Regional Hospital/Cancer Center
American Cancer Society Office
Other  
14.

On what date did you attend the LGFB workshop?  Month:

January
February
March
April
May
June
July
August
September
October
November
December
15.

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

 

50 characters left.
16.

On what day of the week did you attend the LGFB workshop? 

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
17.

At what time of day did you attend the LGFB workshop? 

Early Morning
Mid-day
Afternoon
Evening

About You:
 
Required 18.

Please select your age range:

18 - 29
30 - 39
40 - 49
50 - 59
60 - 69
70 - 79
80 - 89
Prefer not to answer
Required 19.

What is your ethnic background?

African American/Black
American Indian/Alaskan Native
Asian
Chicana or Mexican-American
Other Hispanic/Latina
Caucasian/White
Native Hawaiian or other Pacific Islander
Prefer not to answer
20.

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  
21.

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.

 
22.

 

(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:

23.

Would you like to receive information regarding future LGFB activities?

Yes
No
24.

Additional comments:

 

350 characters left.
25.

FOR NCIC USE ONLY:  Please enter code:


 

50 characters left.