Jason A. Struble
Memorial Cancer Fund, Inc.
 
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   |  Our Challenge  | Educators and Medical Community  |  Donations  |  Feedback  |
 

Feedback

To date we have distributed thousands of videos and tens of thousands brochures and TSE shower card across the United States and the world at large. We know of several success stories but need your help in learning how our efforts have had a positive impact on other young men. We don’t necessarily want names, but rather numbers of people who have successfully caught testicular cancer in time to be treated. We have limited resources and your feed back would help us greatly in our efforts.

If you are a first time visitor or have visited our web site in the past, please feel free to give us your comments!
If you have already received our video, brochures and TSE shower cards please complete the following survey. Your input is very valuable to us.

Name:
School/Organization:  
City/State:
Position:
E-Mail:
Phone:

Do you know of anyone our materials helped with early detection of testicular cancer? Yes No

Can we contact you to learn more? Yes No

Did you show our video in the past 12 months? Yes No

Do you plan to show our video in the next 3 months? Yes No

Since receiving our video, how many times have you shown it?

If applicable, how many people have viewed the video?

Would you like to receive a copy of the video in mpeg or cd form? Yes No

On a scale of 1 to 10, 10 being the best, please rate the following questions:

How would you rate our video? (1-10)

How would you rate our shower card? (1-10)

How would you rate our brochures? (1-10)

What did you like about the video?

How could we improve the video?

Would you like another copy of the video? Yes No - If yes, please specify quantity:

Would you like additional shower cards? Yes No - If yes, please specify quantity:

Would you like additional brochures? Yes No Quantity

Do you know any one who may be interested in learning more about the Jason A. Struble Memorial Cancer Fund, Inc.?

Name:
School/Organization:  
City/State:
Position:
E-Mail:
Phone:

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