Cystic Fibrosis Action Plan-Patient and Caregiver Survey

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* 1. Personal Information

Highest academic degree achieved: High school, Associates, Bachelors, Masters, PhD, MD/DO

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* 2. What year were you born in?

1922

1972

2022

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 3. Do you have Cystic Fibrosis?

I have Cystic Fibrosis

I frequently care for someone with Cystic Fibrosis

Not applicable to me

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Please view the 1.5 minute summary video for this plan and then respond to the questions below.

*****In this video you will see examples of a patient’s action plan with specific medicines. Always keep in mind that not every cystic fibrosis patient will take the same medicines and this is meant to give you an example of what this action plan might look like.

Please view the 1.5 minute summary video for this plan and then respond to the questions below.<br><br><br><br><strong>*****In this video you will see examples of a patient’s action plan with specific medicines. Always keep in mind that not every cystic fibrosis patient will take the same medicines and this is meant to give you an example of what this action plan might look like.</strong><br><br><iframe allowfullscreen="allowfullscreen" frameborder="0" height="315" src="//www.youtube.com/embed/y1XNz5cGDyE?wmode=transparent" title="YouTube video player" width="560"></iframe>

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* 4. How easy or hard would you say it is to read the plan?

1-Very hard

2-Pretty hard

3-In between

4-Pretty easy

5-Very easy

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* 5. How easy or hard would you say it is to understand the information in the plan?

1-Very hard

2-Pretty hard

3-In between

4-Pretty easy

5-Very easy

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* 6. How easy or hard would you say it is to remember the information in the plan?

1-Very hard

2-Pretty hard

3-In between

4-Pretty easy

5-Very easy

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* 7. How easy or hard would you say it is to find the information in the plan?

1-Very hard

2-Pretty hard

3-In between

4-Pretty easy

5-Very easy

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* 8. How easy or hard would you say it is to keep the information in the plan to use later or in the future?

1-Very hard

2-Pretty hard

3-In between

4-Pretty easy

5-Very easy

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* 9. When you think about the design, layout and tone of the plan, how poorly organized or well organized do you think it was?

1-Poorly organized

2-Somewhat poorly organized

3-Unsure

4-Somewhat well organized

5-Well organized

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* 10. When you think about the design, layout and tone of the plan, how unattractive or attractive do you think it was?

1-Unattractive

2-Somewhat unattractive

3-Unsure

4-Somewhat attractive

5-Attractive

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* 11. When you think about the design, layout and tone of the plan, what do you think about the size of the writing?

1-Too small

2-Somewhat too small

3-Just right

4-Somewhat too big

5-Too big

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* 12. When you think about the design, layout and tone of the plan, how alarming or comforting do you think the plan was?

1-Alarming

2-Somewhat alarming

3-Unsure

4-Somewhat comforting

5-Comforting

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* 13. When you think about the design, layout and tone of the plan, how not helpful or helpful do you think it was?

1-Not helpful

2-Somewhat not helpful

3-Unsure

4-Somewhat helpful

5-Very helpful

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* 14. When you think about the design, layout and tone of the plan, what do you think about the spacing between lines?

1-Poor spacing between lines

2-Somewhat poor spacing between lines

3-Unsure

4-Somewhat excellent spacing between lines

5-Excellent spacing between lines

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* 15. After reading this plan, how useful do you feel it will be in managing Cystic Fibrosis at home?

1-Not useful

2-Somewhat not useful

3-Unsure

4-Somewhat useful

5-Very useful

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* 16. After reading this plan, how do you feel your knowledge of Cystic Fibrosis has improved?

1-Small improvement in knowledge

2-Somewhat small improvement in knowledge

3-Unsure

4-Somewhat great improvement in knowledge

5-Great improvement in knowledge

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* 17. After reading this plan, how do you feel your understanding of Cystic Fibrosis have improved?

1-Small improvement in understanding

2-Somewhat small improvement in understanding

3-Unsure

4-Somewhat great improvement in understanding

5-Great improvement in understanding

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* 18. If you receive written information from your doctor or at the hospital, how likely is it that you would read the information?

1-Very unlikely

2-Somewhat unlikely

3-Unsure

4-Somewhat likely

5-Very likely

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* 19. If you receive written information from your doctor or at the hospital, how likely is it that you would use this action plan and the information?

1-Very unlikely

2-Somewhat unlikely

3-Unsure

4-Somewhat likely

5-Very likely

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* 20. If you receive written information from your doctor or at the hospital, how likely is it that you would keep this action plan and the information to use it in the future?

1-Very unlikely

2-Somewhat unlikely

3-Unsure

4-Somewhat likely

5-Very likely