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We want to know what you think about this Guide. Please take a few minutes to answer these 14 questions. We will use your answers to make the Guide better. We will not use your answers for anything else.

1. How easy was it to find your way around the Guide?

2. How easy was it to understand the information in the Guide?

3. How helpful are the six core values when you think about quality care?

4. How much of the Guide's information will you use to make health care choices? These could be choices for your own care. Or you could be helping someone else make choices.

5. How did you find out about this Guide?
(check all that apply)
 a.  NBCCF's web site
 b.  NBCCF's newsletter
 c.  at an NBCCF meeting
 d.  at my doctor's office or care center
 e.  from a group I belong to
 f.   from a family member
 g.  from a friend
 h.  from a newspaper
 i.   from a magazine
 j.   on TV or radio
 k.  other

6. Please check the sentences that describe you.
(Check all that are true.)
 a.  I am worried I might get breast cancer.
 b.  I am worried I might have breast cancer.
 c.  I have breast cancer and am getting care.
 d.  I had breast cancer and have finished getting care.
 e.  I am a family member of someone with breast cancer.
 f.   I am a friend of someone with breast cancer.
 g.  I am a breast cancer activist.
 h.  I am a health care giver.
 i.   I am a breast cancer researcher.
 j.   other

7. What country do you live in?

8. If you live in the United States, which state or territory do you live in?

9. What is your sex?

10. How old are you?

11. What is your race?

12. How much education do you have?

13. Would you like to get information about the National Breast Cancer Coalition?

(If you choose "Yes" you must answer #14)

14. How can we reach you?
(You don't have to fill in these answers unless you want more information.)

First Name
Last Name
Street Address
City
State
Zip Code
Phone
Email

If you have specific comments or questions about the Guide, please send them to:  qualitycare@stopbreastcancer.org


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2001, 2002, 2006 National Breast Cancer Coalition Fund
Last reviewed: March 2006