Beads of Courage Flagship Program - Clinical Experience Survey

Beads of Courage would love to hear from you! We value our partnership in caring with you
and look forward to your comments and suggestions in order to continually improve our programs. We would be very grateful if you could share your honest feedback. Also included is an opportunity to share photos. Thank you and we appreciate all that you do!

By completing this form you are agreeing to share this information with Beads of Courage for program improvements only. Beads of Courage subscribes to basic ethical principles underlying the conduct of research and collection of feedback and will not share this information with any outside entities. *

By completing this form you are agreeing to share this information with Beads of Courage for program improvements only. Beads of Courage subscribes to basic ethical principles underlying the conduct of research and collection of feedback and will not share this information with any outside entities. * I understand and agree to the statement above.
Name of Hospital/Organization
Name: Name: First Last
Email address:
Hospital/Organization Address: Hospital/Organization Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
What Beads of Courage programs have you implemented in your clinical practice? (Please check all that apply)

What Beads of Courage programs have you implemented in your clinical practice? (Please check all that apply) BOC Flagship Program BOC Sibling Program BOC Bead Strong Program BOC Bead Mindful for Clinicians BOC Strand for Strength & Remembrance Workshop BOC Ambassador Workshop BOC DREAM Workshop BOC I'm Fine Workshop BOC Camp Program I have not used BOC programs but would like more information on:
Please indicate the Flagship program(s) you utilize in your clinical practice:

Please indicate the Flagship program(s) you utilize in your clinical practice: Burn Cardiac Chronic Hem/Onc Labor and Delivery NICU
Please indicate the discipline(s) that best describe your clinical practice.

Please indicate the discipline(s) that best describe your clinical practice. Child Life Specialist Child Life Assistant Social Worker Nurse Nurse Practitioner Physician Physician's Assistant Medical Resident Student Intern Pastoral Care Art Therapist Recreational Therapist Music Therapist Physical/Occupational Therapist Other Other

Please mark all that apply
How many years have you been using Beads of Courage in your clinical practice?
Please indicate where/what setting you use the Beads of Courage Programs.

Please indicate where/what setting you use the Beads of Courage Programs. Hospital (inpatient units) Hospital (outpatient clinics) Medical/doctor's office Non-profit/community based organization Support group setting Individual session Private practice Virtual Setting Other Other

Please mark all that apply.
What clinical goals did the program(s) help to reach and were you able to achieve them? (or what clinical goals do you hope to achieve?)
Would you be interested in participating in a clinical advisory group according to the Flagship program you use in your practice?

Would you be interested in participating in a clinical advisory group according to the Flagship program you use in your practice? Yes No Unsure

Please rate the following as honestly as possible. 1 (extremely unsatisfied) to 5 (extremely satisfied)
	1	2	3	4	5	NA
Process of ordering and receiving the program materials	Process of ordering and receiving the program materials1	Process of ordering and receiving the program materials2	Process of ordering and receiving the program materials3	Process of ordering and receiving the program materials4	Process of ordering and receiving the program materials5	Process of ordering and receiving the program materialsNA
Ease of use with materials/facilitation	Ease of use with materials/facilitation1	Ease of use with materials/facilitation2	Ease of use with materials/facilitation3	Ease of use with materials/facilitation4	Ease of use with materials/facilitation5	Ease of use with materials/facilitationNA
Overall participant satisfaction	Overall participant satisfaction1	Overall participant satisfaction2	Overall participant satisfaction3	Overall participant satisfaction4	Overall participant satisfaction5	Overall participant satisfactionNA
Quality of materials as an arts-in-medicine program	Quality of materials as an arts-in-medicine program1	Quality of materials as an arts-in-medicine program2	Quality of materials as an arts-in-medicine program3	Quality of materials as an arts-in-medicine program4	Quality of materials as an arts-in-medicine program5	Quality of materials as an arts-in-medicine programNA
Satisfaction in meeting your clinical goals	Satisfaction in meeting your clinical goals1	Satisfaction in meeting your clinical goals2	Satisfaction in meeting your clinical goals3	Satisfaction in meeting your clinical goals4	Satisfaction in meeting your clinical goals5	Satisfaction in meeting your clinical goalsNA
Quality of support provided/offered by BOC program clinicians	Quality of support provided/offered by BOC program clinicians1	Quality of support provided/offered by BOC program clinicians2	Quality of support provided/offered by BOC program clinicians3	Quality of support provided/offered by BOC program clinicians4	Quality of support provided/offered by BOC program clinicians5	Quality of support provided/offered by BOC program cliniciansNA

Would you recommend the Beads of Courage Flagship programs to others?

Would you recommend the Beads of Courage Flagship programs to others? Yes No Unsure
What works well and what do you like best about using Beads of Courage flagship program?
What, if anything, would you change to improve the experience or satisfaction for those that facilitate and participate in Beads of Courage flagship programs?
Please provide a "mission moment" and/or any direct quotes from participants of the program.

The mission of Beads of Courage is to provide innovative arts in medicine programs for children and teens coping with serious illness, their families, and the clinicians who care for them. A "mission moment" is a positive experience or outcome that occurred during the session.
Do you have any photos that you would be willing to share of the Beads of Courage flagship program in action? (if including people in photos, please obtain a photo consent)

Attach Files
If you included a photo, please tell us who is in the photo:
Does Beads of Courage have your permission to share your testimony?

Your testimony is beneficial to share on our website, social media, grant proposals, with potential new program partners, and more. We appreciate your willingness to share.
I hereby give Beads of Courage, Inc. permission to use this photo/video and content I have provided, in perpetuity, for any purpose deemed appropriate by Beads of Courage, Inc., including but not limited to: print materials; newsletters; signage; on the Beads of Courage website and social media accounts; for media coverage (television, blogs, newspaper, magazine, ezine, ebook, etc.); for educational purposes; for research and scholarly works and presentations; for publicity benefiting Beads of Courage, Inc.

I hereby give Beads of Courage, Inc. permission to use this photo/video and content I have provided, in perpetuity, for any purpose deemed appropriate by Beads of Courage, Inc., including but not limited to: print materials; newsletters; signage; on the Beads of Courage website and social media accounts; for media coverage (television, blogs, newspaper, magazine, ezine, ebook, etc.); for educational purposes; for research and scholarly works and presentations; for publicity benefiting Beads of Courage, Inc. Yes No
I would be interested in participating in an interview with an evaluator or researcher to provide additional feedback

I would be interested in participating in an interview with an evaluator or researcher to provide additional feedback Yes No