Life, Love and Legacy through Pediatric Palliative Care Evaluation
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Enter your contact information.
Name
Address
City
State
Zip Code
Email
Phone
Organization Affiliation
My primary role is (please check all that apply)
Faculty/teacher
Community leader
Clinician
Volunteer
Administration
Family member
Clergy
Other (Please specify)
I have used the film for (please check all that apply):
Teaching
Family support programs
Advocacy within my institution
General community awareness
Advocacy within the health community
Personal use
Legislative/governmental advocacy
Other (please specify)
In what venue did you show the film (please check all that apply)?
Classroom
Clinical setting
Community setting
Faith-based setting
Other (please specify)
Your target audience included (please check all that apply)
Students:
Graduate students
Undergraduate students
High School students
Medical/surgical residents
Medical students
Nursing students
Social work students
Pharmacy students
Chaplain trainees
Other (Please specify)
Your target audience included (please check all that apply)
Professionals:
Physicians
Clergy
Nurses
Teachers
Social workers
Other (please specify)
Pharmacists
Your target audience included (please check all that apply)
Lay community members:
Families
General community
Other (Please specify)
Your target audience included underrepresented minorities.
Yes
No
My goals in purchasing this film were:
Select the appropriate rating for each question.
Low (1)
(2)
Medium (3)
(4)
High (5)
To what extent did the film meet your goals?
In your opinion, how well was the film received by your audience?
How would you rate the overall quality of the film?
Select the appropriate rating for each question.
To what extend did the film inform your audience of:
Low (1)
(2)
Medium (3)
(4)
High (5)
The range of pediatric palliative services
Roles of the palliative care team members
Concerns of the families
Sibling concerns
End-of-life issues
What were the major “take home” messages of the film?
What did you like best about the film?
What was missing from the film?
Do you plan to show the film again?
Yes
No
If Yes, please specify how.
Would you be interested in purchasing shorter (10-15 minute) film modules on special topics in pediatric palliative care?
Yes
No
If "Yes", which topic(s) would be of interest to you?
Grief/bereavement
Spirituality
Sibling issues
Perinatal palliative care
Pain management
Palliative care in a special population (Please specify, ie mitochondrial disease, cancer, etc.)
Other (Please specify)
Overall comments
Northeast Ohio Medical University
