Participant Survey for Cancer Support Services Program

In order to help ensure that we are meeting your needs, we appreciate you taking a few minutes to complete the questions below. Your feedback is anonymous and will help Taos Cancer Support Services (TCSS) improve our quality of service.

Please check the box that best reflects your beliefs about each statement. *

	Strongly Disagree	Disagree	Agree	Strongly Agree
I have received useful information and resources from this program.	Strongly DisagreeI have received useful information and resources from this program. Strongly Disagree	DisagreeI have received useful information and resources from this program. Disagree	AgreeI have received useful information and resources from this program. Agree	Strongly AgreeI have received useful information and resources from this program. Strongly Agree
This program provides quality services.	Strongly DisagreeThis program provides quality services. Strongly Disagree	DisagreeThis program provides quality services. Disagree	AgreeThis program provides quality services. Agree	Strongly AgreeThis program provides quality services. Strongly Agree
This program provides services in a timely manner.	Strongly DisagreeThis program provides services in a timely manner. Strongly Disagree	DisagreeThis program provides services in a timely manner. Disagree	AgreeThis program provides services in a timely manner. Agree	Strongly AgreeThis program provides services in a timely manner. Strongly Agree
This program overall has helped to reduce my stress.	Strongly DisagreeThis program overall has helped to reduce my stress. Strongly Disagree	DisagreeThis program overall has helped to reduce my stress. Disagree	AgreeThis program overall has helped to reduce my stress. Agree	Strongly AgreeThis program overall has helped to reduce my stress. Strongly Agree
This program offers helpful services and resources.	Strongly DisagreeThis program offers helpful services and resources. Strongly Disagree	DisagreeThis program offers helpful services and resources. Disagree	AgreeThis program offers helpful services and resources. Agree	Strongly AgreeThis program offers helpful services and resources. Strongly Agree
This program has helped me cope with my situation.	Strongly DisagreeThis program has helped me cope with my situation. Strongly Disagree	DisagreeThis program has helped me cope with my situation. Disagree	AgreeThis program has helped me cope with my situation. Agree	Strongly AgreeThis program has helped me cope with my situation. Strongly Agree
The program has provided opportunities to strengthen my support systems.	Strongly DisagreeThe program has provided opportunities to strengthen my support systems. Strongly Disagree	DisagreeThe program has provided opportunities to strengthen my support systems. Disagree	AgreeThe program has provided opportunities to strengthen my support systems. Agree	Strongly AgreeThe program has provided opportunities to strengthen my support systems. Strongly Agree
The stress of my financial burden has been reduced due to the assistance from this program.	Strongly DisagreeThe stress of my financial burden has been reduced due to the assistance from this program. Strongly Disagree	DisagreeThe stress of my financial burden has been reduced due to the assistance from this program. Disagree	AgreeThe stress of my financial burden has been reduced due to the assistance from this program. Agree	Strongly AgreeThe stress of my financial burden has been reduced due to the assistance from this program. Strongly Agree
The massage and/or acupuncture treatments (if received) have improved my sense of well-being.	Strongly DisagreeThe massage and/or acupuncture treatments (if received) have improved my sense of well-being. Strongly Disagree	DisagreeThe massage and/or acupuncture treatments (if received) have improved my sense of well-being. Disagree	AgreeThe massage and/or acupuncture treatments (if received) have improved my sense of well-being. Agree	Strongly AgreeThe massage and/or acupuncture treatments (if received) have improved my sense of well-being. Strongly Agree
I would recommend this program to others.	Strongly DisagreeI would recommend this program to others. Strongly Disagree	DisagreeI would recommend this program to others. Disagree	AgreeI would recommend this program to others. Agree	Strongly AgreeI would recommend this program to others. Strongly Agree
Overall, the program has helped improve my quality of life	Strongly DisagreeOverall, the program has helped improve my quality of life Strongly Disagree	DisagreeOverall, the program has helped improve my quality of life Disagree	AgreeOverall, the program has helped improve my quality of life Agree	Strongly AgreeOverall, the program has helped improve my quality of life Strongly Agree

Other Comments?

Who was your CSS Facilitator

Please rate the performance of your CSS Support Group facilitator by choosing one rating for each item below:

	1 - Poor	2	3	4	5 - Excellent
Respectfully listened to participants.	1 - PoorRespectfully listened to participants. 1 - Poor	2Respectfully listened to participants. 2	3Respectfully listened to participants. 3	4Respectfully listened to participants. 4	5 - ExcellentRespectfully listened to participants. 5 - Excellent
Encouraged participation from all group members.	1 - PoorEncouraged participation from all group members. 1 - Poor	2Encouraged participation from all group members. 2	3Encouraged participation from all group members. 3	4Encouraged participation from all group members. 4	5 - ExcellentEncouraged participation from all group members. 5 - Excellent
Respected group members’ needs and differences.	1 - PoorRespected group members’ needs and differences. 1 - Poor	2Respected group members’ needs and differences. 2	3Respected group members’ needs and differences. 3	4Respected group members’ needs and differences. 4	5 - ExcellentRespected group members’ needs and differences. 5 - Excellent
Overall	1 - PoorOverall 1 - Poor	2Overall 2	3Overall 3	4Overall 4	5 - ExcellentOverall 5 - Excellent

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