PNWBD Customer Service & Program Survey
Please take a moment to fill out this survey to improve PNWBD's role in your community
PNWBD Program & Event Evaluation
Please answer the following based on your experience at educational, fundraising, camps and connecting events.
Select the programs you are aware of:
*
Connection Meetings (Portland, Eugene, Southern Oregon and/or Hispanic)
Advocacy Awareness Day at the State Capital
Teen Peak Program
Blood Brotherhood
Couples Retreat
Unite for Bleeding Disorders Walk
Family Camp
Summer Camp for Kids (Camp Tapawingo)
Annual Meeting/Education Day at the Zoo
Insurance Forum
Shooting for the Stars Auction
Women's Conference
Parking Lot Sale
Winter Celebration
Patient Assistance
Select the programs you or a family member have attended in the past year:
*
Connection Meetings (Portland, Eugene, Southern Oregon and/or Hispanic)
Advocacy Awareness Day at the State Capital
Teen Peak Program
Blood Brotherhood
Couples Retreat
Unite for Bleeding Disorders Walk
Family Camp
Summer Camp for Kids (Camp Tapawingo)
Annual Meeting/Education Day at the Zoo
Insurance Forum
Shooting for the Stars Auction
Women's Conference
Parking Lot Sale
Winter Celebration
Patient Assistance
Select your TOP 3 MOST IMPORTANT programs:
*
Connection Meetings (Portland, Eugene, Southern Oregon and/or Hispanic)
Advocacy Awareness Day at the State Capital
Teen Peak Program
Blood Brotherhood
Couples Retreat
Unite for Bleeding Disorders Walk
Family Camp
Summer Camp for Kids (Camp Tapawingo)
Annual Meeting/Education Day at the Zoo
Insurance Forum
Shooting for the Stars Auction
Women's Conference
Parking Lot Sale
Winter Celebration
Patient Assistance
Select 1 - 3 programs you would be willing to cut:
*
Connection Meetings (Portland, Eugene, Southern Oregon and/or Hispanic)
Advocacy Awareness Day at the State Capital
Teen Peak Program
Blood Brotherhood
Couples Retreat
Unite for Bleeding Disorders Walk
Family Camp
Summer Camp for Kids (Camp Tapawingo)
Annual Meeting/Education Day at the Zoo
Insurance Forum
Shooting for the Stars Auction
Women's Conference
Parking Lot Sale
Winter Celebration
Patient Assistance
Select the best option that describes how you feel about the PNWBD programming?
*
Very Positive
Somewhat Negative
Somewhat Positive
Vey Negative
Please explain the reason for your selection above.
What are the reasons you choose your top 3 most important programs?
*
Are there any barriers that prevent you from participating more in the programs that PNWBD offers?
What other programs and/or education would you like to see provided by PNWBD?
Which programs would you be willing to volunteer at?
*
Advocacy Awareness Day
Annual Meeting
Couples Retreat
Summer Camp for Kids
Family Camp
Teem Peak Program
Women's Conference
Unite Walk
Shooting for the Stars
PNWBD Garage Sale
Winter Celebration
I do not wish to volunteer
Other
Communication from PNWBD
Please answer the following based on the communication you receive from PNWBD
Please select if you receive the following mailing:
*
Emails (events/updates)
USPS Mailers (events/updates)
USPS Newsletter
Digital Newsletter
Is there a better way for the PNWBD to communicate with members?
PNWBD Overall
Please answer the following on how you feel about PNWBD and how we can improve.
How do you rate PNWBD’s ability to support the bleeding disorder community? (Range: 1 Star=Needs improvement to 5 Stars=Meets/Exceeds Expectations)?
*
1
2
3
4
5
What are your or your family’s needs that PNWBD could support in the future?
How can PNWBD improve in the future?
Bleeding Disorder Care Team
Please answer the following questions to help your bleeding disorder care team serve you better.
Where do you or your household go for regular medical care related to bleeding disorders?
*
HTC at Oregon Health and Science University
Primary care provider
Prefer not to answer
Other
If you chose primary care provider or other for your bleeding disorder care please explain.
i.e. the medical group or hospital care is received
Are there other services that you would like to see from your bleeding disorder care team?
Are there needs that are not being met by your bleeding disorder care team?
Demographic Information
Please tell us about yourself!
Select the range that includes your age
*
Please Select
0 – 18
19 – 30
31 – 50
51 – 70
71 and older
Prefer not to answer
Select the race or ethnicity that best describes you?
*
Please Select
White/Caucasian
Black or African American
Hispanic
American Indian or Alaskan Native
Asian
Native Hawaiian/Pacific Islander
Multiple ethnicity
Prefer not to answer
Select the gender you identify with
*
Male
Female
Non-Binary
Prefer not to answer
Other:
Select the best option that describes the type of community/area you live in?
*
Rural
Urban
Suburban
Prefer not to answer
Other:
Select all that apply to your household/family
*
Hemophilia A
Hemophilia B
Hemophilia 5
Hemophilia 10
Hemophilia 13
VWB Type 1
VWB Type 2
VWB Type 3
Platelet Disorder
Inhibitors
Hemophilia Carrier
Caregiver
Prefer not to answer
Other
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