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Online Survey
E-summit Survey
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darrussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Primary Phone
*
Cell phone or Main phone.
Secondary Phone
Your Secondary or Home phone
Email
*
I would like for you to mail the free gift for viewing the Health E-Summit to me
*
Yes
No
As part of survey research, we may wish to contact you as follow-up to your participation in the Black Men’s Health E- Summit. If you are willing to be contacted, please check the yes box below (Please note that this is a request for contact information only; This is NOT a request to participate in research)
*
Yes
No
Thank you for your participation in the Black Men’s Health E- Summit. Please provide feedback on the Summit Please choose and check your response to the following statements
After Viewing the Live Webcast
I am better informed about my personal risks for prostate cancer and colon cancer
*
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
I have more knowledge about the recommended age for men to be screened for prostate cancer and how often they should be screened
*
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
I have more knowledge about the recommended age for men to be screened for colon cancer and how often they should be screened
*
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
The information presented will help me make a better decision about whether I should be screened for prostate cancer
*
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
I now understand the benefits, limitations and uncertainties surrounding screening and treatment for prostate cancer
*
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
I became aware of the different opinions that the medical community has about prostate cancer screening and the effectiveness of the PSA (blood) test for prostate cancer screening
*
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
The information presented will allow me to better communicate with a doctor and discuss prostate or colon cancer screening
*
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
The speakers were easy to understand
*
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
This live webcast provided very important health information that men need to know
*
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
I am willing to view a live webcast in the future
*
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
I plan to share what I learned today with others
*
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
Are you a Veteran? (Served in the military)
*
Yes
No
How did you hear about the Summit? (check all that apply)
*
Flyer/Brochure
Internet/Email
Church Announcement
Radio
Internet/Email
Healthcare Provider
Newspaper
Relative/Friend/Co-Worker
Other
What was the other way you heard about the summit?
*
Please Share Any Additional Comments: