!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
STRONGLY DISAGREE / DISAGREE / NO OPINION / AGREE / STRONGLY AGREE1- Videoconferencing, DVD/ VHS,attending via internet made my attendance possible / 1 / 2 / 3 / 4 / 5
2 -I was able to speak freely and ask questions. / 1 / 2 / 3 / 4 / 5
3- I learned new information. / 1 / 2 / 3 / 4 / 5
4- The teaching techniques were conducive to learning. / 1 / 2 / 3 / 4 / 5
5- The information presented was appropriate for my needs. / 1 / 2 / 3 / 4 / 5
6- The handouts were useful for the session. / 1 / 2 / 3 / 4 / 5
7- The educational objectives were met. / 1 / 2 / 3 / 4 / 5
8- The speaker was prepared and informative. / 1 / 2 / 3 / 4 / 5
9- I was comfortable with the camera and other equipment. / 1 / 2 / 3 / 4 / 5
10- I was able to hear questions from the other locations. / 1 / 2 / 3 / 4 / 5
11- I had no trouble hearing the presenter. / 1 / 2 / 3 / 4 / 5
12- I could see the presenter clearly during the session. / 1 / 2 / 3 / 4 / 5
13- My experience was as good as seeing the speaker face to face. / 1 / 2 / 3 / 4 / 5
14- Overall, I am satisfied with this training. / 1 / 2 / 3 / 4 / 5
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