Tele-Education Session Satisfaction Survey

¡Vida! Educational Series

Exercise after Breast cancer: Promoting Healthy, Happy Recovery

October 11, 2012 Location: ______

General Information Survey

1- I am a: (please circle all that apply) Other ______Breast cancer survivor Relative of a breast cancer survivor Caregiver of a breast cancer survivor Health care professional______Lay health worker/ promoter CPG (Community Partner Group member) 2- My residence is in city/town: ______county: ______zip code: ______3- My health insurance is: (please circle all that apply) AHCCCS PCAP Private (please specify) (HMO/ PPO) ______Other______No health insurance Medicare ______4- Age: < 40 40- 49 50- 64 65 + Gender:

5- Race/ Ethnicity: (please circle all that apply) Native American Caucasian Mixed race Asian/ Pacific Islander African American Hispanic Other _____ 6- How did you hear about this session?

Before viewing the session:

My knowledge about this topic is: (circle only one answer) none at all very little somewhat a lot

Please answer these questions before viewing this session:

1) What restrictions on exercise are valid after mastectomy? (choose all that apply) a) avoid vigorous aerobic activity

b) avoid lifting weights or objects over 10 lbs.

c) start out with low weights and increase incrementally.

d) exercise only under supervision by a physical therapist.

2) Identify three or more health benefits of exercise after a cancer diagnosis.

3) Evidence supports a link between exercise and reduction in cancer recurrence for which types of cancer? (choose all that apply) a) pancreatic cancer

b) lung cancer

c) breast cancer

d) colorectal cancer

4) For how many cancer patients do you plan to prescribe or recommend physical activity in the next month?

1 ¡Vida! Educational Series

______After viewing the session: My knowledge about this topic is: (circle only one answer) none at all very little somewhat a lot

Please answer these questions after viewing this session:

1) What restrictions on exercise are valid after mastectomy? (choose all that apply) a) avoid vigorous aerobic activity

b) avoid lifting weights or objects over 10 lbs.

c) start out with low weights and increase incrementally.

d) exercise only under supervision by a physical therapist.

2) Identify three or more health benefits of exercise after a cancer diagnosis.

3) Evidence supports a link between exercise and reduction in cancer recurrence for which types of cancer? (choose all that apply) a) pancreatic cancer

b) lung cancer

c) breast cancer

d) colorectal cancer

4) For how many cancer patients do you plan to prescribe or recommend physical activity in the next month?

5) As a result of viewing this presentation, will you? (circle all that apply):

Seek medical care Yes No Share the information with others, if yes, who: ______Yes No Change your practice Yes No Other: ______

______

AFTER VIEWING THE SESSION PLEASE COMPLETE THIS SURVEY

Sponsored by the University of Arizona College of Medicine at the University of Arizona Medical Center

ATP – CLINICAL CARE CONFERENCE SERIES GRAND ROUNDS TEACHING EVALUATION

YOUR NAME (please print): DEGREE / JOB TITLE:

TODAY’S DATE: 10/11/12 ARIZONA TELEMEDICINE PROGRAM SITE AFFILIATION:

STATUS: STUDENT  FELLOW  FACULTY  HOUSE OFFICER  OTHER 

PROGRAM TITLE: Exercise Promotes Cancer Recovery SPEAKER: Joy Kiviat, PhD,MSN,RN (OCN), Clinical Instructor, ACSM certified Cancer Exercise Trainer

STRONGLY NO STRONGL DISAGREE DISAGRE OPINION AGREE Y E AGREE

This topic is of interest to me 1 2 3 4 5 This topic is relevant to my practice and will ultimately 1 2 3 4 5 improve patient care

I learned new information 1 2 3 4 5 The teaching techniques were conducive to learning 1 2 3 4 5 The speaker was prepared and informative 1 2 3 4 5 The educational objectives were met 1 2 3 4 5 I would not have been able to attend a lecture on this topic if 1 2 3 4 5 it had not been available via the ATP What other topics would you like to see addressed?

Did you feel there was a bias toward any particular product or company? Yes__ NO __ If yes, please explain: COMMENTS:

THANK YOU

You may submit the completed forms in any of the following ways:

Via fax: (520) 626- 5583 Attn: Bettina Hofacre

Via mail: University of Arizona Cancer Center Attn: Bettina Hofacre 1515 N. Campbell Ave Tucson, AZ 85724

Via e-mail to: [email protected]

If you have any questions please contact:

Bettina Hofacre at (520) 626-3265