LLS24966 MCL Eval

Mantle Cell Lymphoma Video Evaluation

1. Please select the option that best describes you: *

Please select subcategory *

1a. What is your year of birth? *

I verify that I am older than 18 years of age. LLS cannot correspond with minors without parental consent.

2. Do you describe yourself as a man, a woman, or in some other way? *

Man

Woman

Prefer not to disclose

Some other way, please specify Some other way, please specify

3. What is your ZIP code or postal code? *

4. What is your Race? (check all that apply)

Are you Hispanic/Latino?

Yes

No

Prefer not to disclose

5. Have you or the patient been diagnosed with a blood cancer? *

N/A

Yes

No

If no, please tell us the type of cancer with which you/patient were diagnosed: *

If yes, when were you/patient diagnosed?

Month *

Day *

Year *

Check if approximate date

Month

Day

Year

Check if approximate date

If yes, please tell us what type of blood cancer (check all that apply): *

Are you or the patient currently being treated? *

Yes

No

What treatments have you or the patient had? (check all that apply) *

6. Are you or the patient presently in or ever participated in a clinical trial? *

N/A

Yes

No

7. How effective was Jacob D. Soumerai, MD, in explaining: *

	Not Effective	Somewhat Effective	Effective	Very Effective
What Mantle Cell Lymphoma (MCL) is and how it is diagnosed	Not Effective	Somewhat Effective	Effective	Very Effective
The history of MCL treatments	Not Effective	Somewhat Effective	Effective	Very Effective
The future of MCL treatments	Not Effective	Somewhat Effective	Effective	Very Effective

8. Following this program, do you feel more prepared to discuss cancer diagnoses challenges with a healthcare professional? *

N/A

Yes

No

Please explain how:

9. Please describe any information you expected to get from this program but did not receive.

10. Please give us any additional feedback about this program.

Thank you for your comments.

If you would like more information from LLS, please provide your contact information below:

First Name:

Last Name:

Email Address:

or complete mailing address, including ZIP/postal code:

If you have additional questions following this program, please contact an LLS Information Specialist toll-free at (800) 955-4572 or www.LLS.org/ContactUs

* Indicates required field

Physician	PCP
Nurse	NP
PA	Pharmacist
Medical Assistant	Pharmaceutical Rep
Radiation Tech	Psychologist
Social Worker	Hospital/Homebound Teacher
Other HCP Other HCP