Tele-Education Session Satisfaction Survey

!Vida! Breast Cancer Education For Survivors, Families & Caregivers and Providers Via Telemedicine

HCP Session 12:Cognitive Dysfunction After Breast Cancer Treatment

Date: ______Location: ______

General Information Survey

BEFORE VIEWING THE SESSION, PLEASE COMPLETE THIS SURVEY

Instructions: Please circle the correct answer/s:

1- I attended/viewed this session:

Via videoconference In-person Via internetDVD/ 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/ promotor(a)

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- The following describe me:

Age ______Gender ______

5- I describe my ethnicity as:

HispanicNon-Hispanic

6- I describe my race as:

WhiteAmerican Indian Pacific Islander

Asian Other (please specify) ______

7- The highest grade of school that I completed is ______

8-At home, I speak:

English only Spanish only English Spanish

Other (please specify ______

9- I needed this presentation translated into Spanish:

Yes No

10- I heard abut this session from ______

11- I attended a Vida session before?

No Yes If yes, this is my #1,#2,#3,#4,#5,#6,#7,#8,#9, #10, #11, #12Vida session attended.

¡Vida! Pre-Knowledge Assessment Survey

BEFORE VIEWING THE SESSION, PLEASE COMPLETE THIS SUVEY

HCP Session 12:Cognitive Dysfunction After Breast Cancer Treatment

Instructions: Please read the following questions and provide the best answer:

1. My knowledge about this topic is: (circle the best answer)

none at all very little somewhata lot

2.Which of the following are symptoms of chemo brain?

a)disturbance of long-term memory

b) decreased ability to reason

c) trouble concentrating and focusing

d) disruption of the ability to perform a talent

3. How long does chemo brain last?

a) from the start of treatment to the end of treatment

b) up to five years after chemotherapy treatment is completed

c) varies from person to person

d) up to ten years after chemotherapy treatment is completed

4. Which of the following factors contributes tochemo brain?

a) treated depression

b) anemia

c) endorphins

d)use of growth factors

5. Identify which of the following is a recommendation for managing chemo brain?

a) there is no known intervention for chemo brain

b) set up diverse schedules without routines

c) engage in physical activity

d) ignore difficulties

6. Identify which of the following symptoms might necessitate immediate medical attention.

a) decreased congnitive flexibility

b) morning headache

c) depression

d) fatigue

PLEASE DO NOT COMPLETE ANY ADDITIONAL FORMS UNTIL AFTER YOU HAVE VIEWED THE ENTIRE PRESENTATION

PLEASE PROCEED AND VIEW

THE VIDA! PRESENTATION

Educational Objectives for this Session

• Define cognitive dysfunction
• Identify effects of chemotherapy on cognitive function
• Understand potential causes
• Outline patient concerns and usual care
• Self management strategies for “chemo brain”
• Identify symptoms that would necessitate medical attention

Session Satisfaction Survey

AFTER VIEWING THE SESSION, PLEASE COMPLETE THIS SURVEY

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! Post-Knowledge Assessment Survey

AFTER VIEWING THE SESSION, PLEASE COMPLETE THIS SURVEY

HCP Session 12:Cognitive Dysfunction After Breast Cancer Treatment

Instructions: Please read the following questions and provide the best answer:

1.After watching this presentation, my knowledge about this topic is: (circle the best answer)

none at all very little somewhata lot

2.Which of the following are symptoms of chemo brain?

a)disturbance of long-term memory

b) decreased ability to reason

c) trouble concentrating and focusing

d) disruption of the ability to perform a talent

3. How long does chemo brain last?

a) from the start of treatment to the end of treatment

b) up to five years after chemotherapy treatment is completed

c) varies from person to person

d) up to ten years after chemotherapy treatment is completed

4. Which of the following factors contributes tochemo brain?

a) treated depression

b) anemia

c) endorphins

d)use of growth factors

5. Identify which of the following is a recommendation for managing chemo brain?

a) there is no known intervention for chemo brain

b) set up diverse schedules without routines

c) engage in physical activity

d) ignore difficulties

6. Identify which of the following symptoms might necessitate immediate medical attention.

a) decreased congnitive flexibility

b) morning headache

c) depression

d) fatigue

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

or

Via mail : Arizona Cancer Center

ATTN: Angela Valencia

1515 N. Campbell Ave

Tucson, AZ85724

or

Via e-mail to:

If you nave any questions please call:

(520) 626-3265

Bettina Hofacre

1

Vida! Session Packet for HCP PLEASE KEEP ALL FORMS TOGETHER