Arizona Myeloma Network (AzMN)
Cancer Caregivers’ Education/Support Program
Discovery Questionnaire

 
Please take a few minutes and help us learn what you would find most helpful in being an effective and healthy caregiver of your loved one. Your responses will be used to assist AzMN in developing a Cancer Caregivers’ Education/Support Program that best meets the needs of a broad spectrum of participants. Your responses, which will be held strictly confidential, will also help us demonstrate to potential funders the critical need for such services.
  
Name
  
Email Address
  
Phone Number
  
A.
  
Interest/Involvement: Please choose ONE answer that best fits how you feel and check that box.
 
Item
Strongly Disagree
Disagree
Agree
Strongly Agree
1. Cancer Caregiver education is an important service for AzMN to offer.
2. I would be interested in attending a 10- hour Cancer Caregivers’ Education/ Support series of sessions.
3. I would prefer the 10-hour series be held from 6:00 p.m. – 8:30 p.m. on a weeknight (4 two and one-half hour sessions).
4. I would prefer the 10-hour series be held from 8:30 a.m. – 1:00 p.m. on a Saturday (2 five hour sessions).
5. I would be willing to pay a $50 fee for the 10-hour series to assist with administrative costs (materials, supplies, etc.).
B.
  
Workshop Topics: Please choose one answer that best indicates how helpful
you would find the following workshop topics:
 
 
Strongly Disagree
Disagree
Agree
Strongly Agree
The Role of Caregiving – What it Means
Taking Care of Yourself
Building Cooperative Relationships
Preventing and Solving Problems
Accessing and Developing Resources
C.
  
What other topics would be important to you?
D.
  
How might we further support you in your role as caregiver?
   
Thank you for helping develop a relevant and meaningful education program for caregivers. If you know anyone else who might be interested, please send this survey to them.

If you would be interested in being notified about the outcome of our survey, and/or our schedule for seminars in 2010, please indicate below.
E.
  
Please let me know the results of your survey:  Yes    No
F.
  
Please let me know when you are scheduling a Caregiver’s Seminar:  Yes    No
     
   
The Arizona Myeloma Network is a 501(c)(3) not-for-profit organization. No goods or services were provided in consideration of this contribution. Your gift is tax-deductible to the extent allowed by law. The Arizona Myeloma Network’s tax identification number is 32- 0169742.

20280 N 59th Ave, Suite #115 448 • Glendale, AZ 85308 • 623-388-6837 • Fax – 623-245-6580
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