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Submit a question
Complete the Program Evaluation
Name
*
Email
*
I participated as: (select one).
*
Caregiver
Community Member
Family Member
Friend/Concerned Individual
Healthcare Professional
LLS Staff
Patient
Volunteer
Other
Which best describes you?
Parent
Sibling
Child
Spouse/Partner/Significant Other
Extended Family Member
Which best describes you?
Hospital/Homebound Teacher
Pharmacist
Psychologist
Medical Assistant
Physician
Radiation Therapies
Nurse
Physician Assistant
Social Worker
Nurse Practitioner
Primary Care Physician (PCP)
Other
Pharmaceutical Rep
As a result of participating in this program, to what extent do you agree with the following statements?
Strongly Disagree
Disagree
Agree
Strongly Agree
I know what financial toxicity means
I know what financial toxicity means Strongly Disagree
I know what financial toxicity means Disagree
I know what financial toxicity means Agree
I know what financial toxicity means Strongly Agree
I am knowledgeable about the effects of financial toxicity on cancer patients
I am knowledgeable about the effects of financial toxicity on cancer patients Strongly Disagree
I am knowledgeable about the effects of financial toxicity on cancer patients Disagree
I am knowledgeable about the effects of financial toxicity on cancer patients Agree
I am knowledgeable about the effects of financial toxicity on cancer patients Strongly Agree
I know how to reduce financial toxicity
I know how to reduce financial toxicity Strongly Disagree
I know how to reduce financial toxicity Disagree
I know how to reduce financial toxicity Agree
I know how to reduce financial toxicity Strongly Agree
As a result of participating in this program, to what extent do you agree with the following statements?
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I plan to educate my patients/caregivers about questions they need to ask healthcare professionals regarding financial toxicity
I plan to educate my patients/caregivers about questions they need to ask healthcare professionals regarding financial toxicity Strongly Disagree
I plan to educate my patients/caregivers about questions they need to ask healthcare professionals regarding financial toxicity Disagree
I plan to educate my patients/caregivers about questions they need to ask healthcare professionals regarding financial toxicity Neutral
I plan to educate my patients/caregivers about questions they need to ask healthcare professionals regarding financial toxicity Agree
I plan to educate my patients/caregivers about questions they need to ask healthcare professionals regarding financial toxicity Strongly Agree
I plan to discuss clinical trials with patients and caregivers
I plan to discuss clinical trials with patients and caregivers Strongly Disagree
I plan to discuss clinical trials with patients and caregivers Disagree
I plan to discuss clinical trials with patients and caregivers Neutral
I plan to discuss clinical trials with patients and caregivers Agree
I plan to discuss clinical trials with patients and caregivers Strongly Agree
What is your date of birth
What is your gender?
Male
Female
What is your zip/postal code?
What is your Race? (check all that apply)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White or Caucasian
I prefer not to disclose
Other race
Please specify
Ethnicity: Are you Latino?
Yes
No
I prefer not to disclose
How did you hear about the program
Conference Handout
Emailed Invitation
Friend/Colleague
Google Search
Local LLS
LLS Podcast
LLS Website
LLS Community
Mailed Invitation
Newsletter
Physician/Healthcare Professional
Poster
Triage Cancer
Other
Please describe
Please describe any information you expected to get from this program but did not receive.
Please give us additional feedback about the program.
Website
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