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Expanding Treatment Options for CLL | September 23, 2017

Page One

Thank you for participating in our program. Please take a few moments to complete this questionnaire to help us develop future programs for people living with Chronic Lymphocytic Leukemia (“CLL”).

1. Please choose the one statement that best describes you. (Choose only one): *This question is required.

Please enter an 'other' value for this selection.

When were you diagnosed? *This question is required.

What treatments are you currently receiving or have received in the past (check all that apply)

Space Cell	Current	Past
Adriamycin (doxorubicin)	Adriamycin (doxorubicin): Current	Adriamycin (doxorubicin): Past
Arzerra (ofatumumab)	Arzerra (ofatumumab): Current	Arzerra (ofatumumab): Past
Campath (alemtuzumab)	Campath (alemtuzumab): Current	Campath (alemtuzumab): Past
Cytoxan (cyclophosphamide)	Cytoxan (cyclophosphamide) : Current	Cytoxan (cyclophosphamide) : Past
Fludara (fludarabine)	Fludara (fludarabine) : Current	Fludara (fludarabine) : Past
Gazyva (obinutuzumab)	Gazyva (obinutuzumab) : Current	Gazyva (obinutuzumab) : Past
Imbruvica (ibrutinib)	Imbruvica (ibrutinib) : Current	Imbruvica (ibrutinib) : Past
Leukeran (chlorambucil)	Leukeran (chlorambucil): Current	Leukeran (chlorambucil): Past
Leustatin (cladribine)	Leustatin (cladribine): Current	Leustatin (cladribine): Past
Nipent (pentostatin)	Nipent (pentostatin): Current	Nipent (pentostatin): Past
Oncovin (vincristine)	Oncovin (vincristine): Current	Oncovin (vincristine): Past
Prednisone	Prednisone: Current	Prednisone: Past
Revlimid (lenalidomide)	Revlimid (lenalidomide): Current	Revlimid (lenalidomide): Past
Rituxan (rituximab)	Rituxan (rituximab): Current	Rituxan (rituximab): Past
Treanda (bendamustine)	Treanda (bendamustine): Current	Treanda (bendamustine): Past
Stem cell transplantation	Stem cell transplantation: Current	Stem cell transplantation: Past
Venclexta (venetoclax)	Venclexta (venetoclax) : Current	Venclexta (venetoclax) : Past
Other (please specify below)	Other (please specify below): Current	Other (please specify below): Past

If you chose "other" above, please specify.

Are you participating in a clinical trial now or have you in the past?

Do you know what medicine is/was being investigated?

Would you consider participating in a clinical trial?

Would you consider being part of a small group discussion to help guide the development of new medicines?

If you are interested in sharing more about your experience living with CLL, please provide us with your contact information. Email address and/or phone number:

2. How would you rate today’s discussion?

How knowledgeable do you consider yourself in understanding CLL (choose your answer on the scale below - 10 being the highest)?

*This question is required.

1 (Not knowledgable at all)	2	3	4	5	6	7	8	9	10 (Very knowledgable)
1 (Not knowledgable at all)	2	3	4	5	6	7	8	9	10 (Very knowledgable)

4. How much did this program increase your understanding of CLL?

1 (Not at All)	2	3	4	5	6	7	8	9	10 (A Great Deal)
1 (Not at All)	2	3	4	5	6	7	8	9	10 (A Great Deal)

5. How well did the program help you understand the current treatments and research? *This question is required.

1 (Not at All)	2	3	4	5	6	7	8	9	10 (A Great Deal)
1 (Not at All)	2	3	4	5	6	7	8	9	10 (A Great Deal)

6. How well did this program give you more confidence and help you feel in control as you face your disease?

1 (Not at All)	2	3	4	5	6	7	8	9	10 (A Great Deal)
1 (Not at All)	2	3	4	5	6	7	8	9	10 (A Great Deal)

7. How would you rate our participants?

Space Cell	Excellent	Good	Fair	Poor	N/A
Michael Keating, MB, BS	Michael Keating, MB, BS: Excellent	Michael Keating, MB, BS: Good	Michael Keating, MB, BS: Fair	Michael Keating, MB, BS: Poor	Michael Keating, MB, BS: N/A
Jeff Sharman, MD	Jeff Sharman, MD: Excellent	Jeff Sharman, MD: Good	Jeff Sharman, MD: Fair	Jeff Sharman, MD: Poor	Jeff Sharman, MD: N/A
Kathryn Kolibaba, MD	Kathryn Kolibaba, MD: Excellent	Kathryn Kolibaba, MD: Good	Kathryn Kolibaba, MD: Fair	Kathryn Kolibaba, MD: Poor	Kathryn Kolibaba, MD: N/A
Stephen E. Spurgeon, MD	Stephen E. Spurgeon, MD: Excellent	Stephen E. Spurgeon, MD: Good	Stephen E. Spurgeon, MD: Fair	Stephen E. Spurgeon, MD: Poor	Stephen E. Spurgeon, MD: N/A
Nora Larson, MSW, CSWA, LICSWA	Nora Larson, MSW, CSWA, LICSWA: Excellent	Nora Larson, MSW, CSWA, LICSWA: Good	Nora Larson, MSW, CSWA, LICSWA: Fair	Nora Larson, MSW, CSWA, LICSWA: Poor	Nora Larson, MSW, CSWA, LICSWA: N/A
Christine, Patient Advocate	Christine, Patient Advocate: Excellent	Christine, Patient Advocate: Good	Christine, Patient Advocate: Fair	Christine, Patient Advocate: Poor	Christine, Patient Advocate: N/A
Ralph, Patient Advocate	Ralph, Patient Advocate: Excellent	Ralph, Patient Advocate: Good	Ralph, Patient Advocate: Fair	Ralph, Patient Advocate: Poor	Ralph, Patient Advocate: N/A
Andrew Schorr, Host	Andrew Schorr, Host: Excellent	Andrew Schorr, Host: Good	Andrew Schorr, Host: Fair	Andrew Schorr, Host: Poor	Andrew Schorr, Host: N/A

8. How would you rate the sessions?

Space Cell	Excellent	Good	Fair	Poor	N/A
Meet Other Patients and Care Partners	Meet Other Patients and Care Partners: Excellent	Meet Other Patients and Care Partners: Good	Meet Other Patients and Care Partners: Fair	Meet Other Patients and Care Partners: Poor	Meet Other Patients and Care Partners: N/A
Understanding CLL and Current Treatment Options	Understanding CLL and Current Treatment Options: Excellent	Understanding CLL and Current Treatment Options: Good	Understanding CLL and Current Treatment Options: Fair	Understanding CLL and Current Treatment Options: Poor	Understanding CLL and Current Treatment Options: N/A
Developing CLL Research: What Could It Mean for You	Developing CLL Research: What Could It Mean for You: Excellent	Developing CLL Research: What Could It Mean for You: Good	Developing CLL Research: What Could It Mean for You: Fair	Developing CLL Research: What Could It Mean for You: Poor	Developing CLL Research: What Could It Mean for You: N/A
Monitoring Your CLL and Choosing a Treatment Path	Monitoring Your CLL and Choosing a Treatment Path: Excellent	Monitoring Your CLL and Choosing a Treatment Path: Good	Monitoring Your CLL and Choosing a Treatment Path: Fair	Monitoring Your CLL and Choosing a Treatment Path: Poor	Monitoring Your CLL and Choosing a Treatment Path: N/A
Meet the Patient Panel: Inspiring Stories and Advice	Meet the Patient Panel: Inspiring Stories and Advice: Excellent	Meet the Patient Panel: Inspiring Stories and Advice: Good	Meet the Patient Panel: Inspiring Stories and Advice: Fair	Meet the Patient Panel: Inspiring Stories and Advice: Poor	Meet the Patient Panel: Inspiring Stories and Advice: N/A
Tools for Living Well With CLL	Tools for Living Well With CLL: Excellent	Tools for Living Well With CLL: Good	Tools for Living Well With CLL: Fair	Tools for Living Well With CLL: Poor	Tools for Living Well With CLL: N/A
Q&A	Q&A: Excellent	Q&A: Good	Q&A: Fair	Q&A: Poor	Q&A: N/A

What suggestions can you provide to help us improve our program?

9. Program Content – please provide suggestions of topics you would like us to cover in the future.

10. Breakout Session – Did you find the breakout session at the beginning of the program useful? If so, why?

11. Additional comments

12. Which of the following actions will you take as a result of this program? (Check all that apply)

13. If we produced a similar program via live stream on the Internet, would you be interested in attending online again?

14. What is your gender?

15. What is your age?

16. Where do you live?

Please enter an 'other' value for this selection.
Please enter an 'other' value for this selection.