JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
NYCHC 2020 Needs Assessment
This questionnaire will be used to improve the programs and services offered by the chapter. The questions are directed for people with bleeding disorders themselves or family members.
Apriete aquí para llenar la encuesta en español:
https://forms.gle/EYkYu2gqBErt1xce8
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Section 1: Demographics
Which categories best describe you? (select all that apply)
*
Person with a bleeding disorder
Parent of a person with a bleeding disorder
Spouse/partner/friend of a person with a bleeding disorder
Carrier
Provider (Physician, Nurse, Social Worker, Physical Therapist, etc.)
Connected to the community
Work for a company serving the bleeding disorders community
Active inhibitor for yourself or your family
Past diagnosis of an inhibitor for yourself or your family, but no longer active
Woman with a bleeding disorder
Chapter volunteer
Other:
Required
For you, if you have a bleeding disorder, or the people in your household with a bleeding disorder, please indicate the following ages with bleeding disorders (select all that apply):
0-6
7-12
13-18
18-24
25-39
40-60
60 plus
Gender
Female
Male
Other:
Clear selection
Racial Identity (Categories based on US Census; check all that apply)
White
Black or African American
Hispanic or Latino
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Some Other Race
What languages do you speak?
Your answer
Where do you usually reside (check all that apply)?
New York City
Manhattan
Brooklyn
Queens
Bronx
Staten Island
Long Island (not in New York City)
Westchester County
Other New York State
New Jersey (North)
New Jersey (Central)
Other New Jersey
Connecticut
Other:
Clear selection
What was your estimated household income in the past 12 months? (Categories based on 80% of NYC area median income for a household of 3)
$81,920 or less
$81,921 or more
Clear selection
What type of bleeding disorder do you /your family have? (select all that apply)
Hemophilia A
Hemophilia B
Von Willebrand Disease (VWD)
Other bleeding disorder
If you or a family member has hemophilia, how is the severity categorized?
Mild
Moderate
Severe
Not Applicable
I don't know
If you or a family member has VWD, what type?
Type 1
Type 2
Type 3
Not applicable
I don't know
Have you or a family member received care for your bleeding disorder from a Hemophilia Treatment Center in the past 12 months?
Yes
No
Not applicable
Clear selection
What is the name of your usual Hemophilia Treatment Center
Mount Sinai
Montefiore
LIJ
Weill Cornell
Mary Gooley
SUNY Upstate
Western New York BloodCare
Albany Medical Center
Newark Beth Israel
Children's Hospital of Philadelphia
St. Michael's Medical Center (Newark)
Robert Wood Johnson (New Brunswick)
Conneticut Children's
Yale HTC
Not applicable
I don't know
Other:
Clear selection
In the past 12 months, did you or a family member go to an HTC for your annual comprehensive visit?
Yes
No
Not Applicable
Clear selection
If you didn't go to an HTC for an annual comprehensive visit in the past 12 month, please explain the reason.
Your answer
In the past 12 months, did you or a family member go to a non-HTC hematologist for your bleeding disorder?
Yes
No
Not Applicable
Clear selection
How often in a year do you or your family meet in person with your hematologist?
Less than once a year
1-2 times a year
3-5 times a year
6-10 times a year
More than 10 times a year
I don't know
Clear selection
If you didn't meet with your hematologist in person, were you in contact in some other way, such as by telephone, email, or video visit?
Yes
No
Not Applicable
Clear selection
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of New York City Hemophilia Chapter.
Report Abuse
Forms
