Participant Demographics
What is the patient's age range?*
What type of congenital hemophilia does the patient have?*
What caregiver role do you hold?*
(please specify)
What is your age range?*
Participant History
What was your method of participation for this program?*
Have you previously attended a summit(s)?*
If yes, which one?
Program Effectiveness
Please use the following codes to evaluate:
1 = Needs Improvement, 2 = Below Average, 3 = Average, 4 = Above Average, 5 = Excellent
Compared with all other programs that I have participated in over the past year, I would rate this program as:*
My knowledge level was increased as a result of this program:*
What percentage of the information of this summit was new to you?*
Future Educational Topics
Please list any other topics you would like to see in future educational activities:
Activity Outcomes Measurement
Please use the following codes to evaluate:
1 = No Change, 2 = Little Change, 3 = May Change, 4 = Some Change, 5 = Will Change
Do you expect your management strategies in area will change within the next 6 months as a result of participating in this program?*
State a change you are committed to making in the management of your bleeding disorder:
You have permission to contact me in approximately 12 weeks to determine if I have changed the way I manage my bleeding disorder as a result of this program.*
Please contact me by:*
() –
() –
Submit Evaluation