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Hemophilia and Bleeding Disorders of Alabama, Inc.
Members Survey
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Title
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First Name *
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Last Name *
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Email Address *
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Home Phone Number *
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1. We are very interested in learning what the bleeding disorder community thinks of Hemophilia and Bleeding Disorders of Alabama, Inc. (HBDA) and the programs and service it offers. Please take a few moments to
complete this survey to help us serve your needs. |
| 2. Which of the following types of programs or services have you or your family used or participated during the past year? (CHECK ALL THAT APPLY) |
Fundraising Events
Fundraising Events
Family Programs (Annual Meeting)
Annual Christmas Luncheon
Youth Programs (Camp Clot Not)
Educational Seminars and Conferences (Sponsored by Pharmaceutical or Home Health)
HBDA Newsletters
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3. How valuable are the programs or services listed below to you and your family?
(CHECK THE APPROPRIATE RESPONSES.) |
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| (a) SUMMER CAMP PROGRAM (Sponsors youth that would like to attend summer camp) |
Very Valuable
Valuable
Somewhat Valuable
Not Very Valuable
Unaware of Program
Do Not Utilize |
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| (b) NEWSLETTER (Informational Material) |
Very Valuable
Valuable
Somewhat Valuable
Not Very Valuable
Unaware of Program
Do Not Utilize |
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| (c) EDUCATIONAL SEMINARS (Informative lectures and workshops) |
Very Valuable
Valuable
Somewhat Valuable
Not Very Valuable
Unaware of Program
Do Not Utilize |
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| (d) FUNDRAISING EVENTS (Raise funds to support Camp and future family programs) |
Very Valuable
Valuable
Somewhat Valuable
Not Very Valuable
Unaware of Program
Do Not Utilize |
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| (e) HBDA WEBSITE (Current information on happenings along with links to services available) |
Very Valuable
Valuable
Somewhat Valuable
Not Very Valuable
Unaware of Program
Do Not Utilize |
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How did you hear about these programs and services? (CHECK ALL THAT APPLY)
Contacted HBDA directly
Received information in the mail
HBDA Website
Hemophilia Treatment Center Staff
Unaware of some of these programs before reading this survey
Other:
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Please list the programs you were unaware of before reading this survey:
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5. Is there anything that keeps you from using the programs and services offered by HBDA, Inc.? If so, please describe (i.e. distance, didn't know about them).
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| 6. Below is a list of patient and family NEEDS identified by HBDA. How important is the development of programs and services in these areas to you and your family? (CHECK THE APPROPRIATE RESPONSE) |
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| (a) Communication with others affected by bleeding disorders |
Very Important
Important
Somewhat Important
Not Important |
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| (b) Youth Programs and Services |
Very Important
Important
Somewhat Important
Not Important |
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| (c) Adult Programs and Services |
Very Important
Important
Somewhat Important
Not Important |
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| (d) Consumer involvement in program planning |
Very Important
Important
Somewhat Important
Not Important |
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| (e) Women's Outreach |
Very Important
Important
Somewhat Important
Not Important |
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(f) Increased awareness of HBDA programs
and services |
Very Important
Important
Somewhat Important
Not Important |
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| (g) Patient and family involvement with HBDA events (i.e. fund raising & recognition events) |
Very Important
Important
Somewhat Important
Not Important |
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7. Do you have NEEDS other than those listed above that you would like HBDA to address? If so, please describe.
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| We would like to ask some general questions that will assist us in interpreting survey findings. Please answer the following questions to the best of your ability. |
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1. Number of individuals in your household with a bleeding disorder.
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2. My relationship to the person(s) with a bleeding disorder is
(CHECK ALL THAT APPLY).
Myself
Parent
Sibling
Grandparent
Spouse/Partner
Other |
3. My family is affected by the following bleeding disorder(s):
(CHECK ALL THAT APPLY & CHECK SEVERITY.)
Hemophilia A Hemophilia B Von Willebrand
Mild Mild Type 1 (mild)
Moderate Moderate Type 2 (or other variant)
Severe Severe Type 3 (severe)
Inhibitor Inhibitor Unsure |
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Birmingham
Mobile
Home Infusion (Self)
Home Health Company
Family Physician
Emergency Room
Other:
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Within 30 minutes driving distance
1-2 hours
30 minutes to 1 hour
More than 2 hours driving distance |
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| (a) Providing programs that meet the current needs of you and your family. |
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| (b) Quality of information on programs and services offered by HBDA. |
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| (c) Helpfulness of HBDA staff to request for assistance. |
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| (d) Overall assessment of HBDA programs and services. |
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Additional Comments:
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| The following is a list of VOLUNTEER OPPORTUNITIES WITH HBDA. How interested would you or your family be in serving? (CHECK THE APPROPRIATE RESPONSE) |
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| (a) Fundraising Events - (sponsorship or particiation) |
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(b) Newsletter - (seeking advertising or submitting information relevant to the bleeding disorders community)
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| (c) Family Retreats/Picnics - (planning, seeking sponsors and donations, execution of event, etc.) |
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| (d) Camp Clot Not - (seeking sponsors, donations, volunteering) |
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| (e) Parent to Parent Program - (educational programs and materials for parenting skills and support program) |
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| (f) Advocacy on behalf of the bleeding disorders community |
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