1. Are you a cancer survivor (a survivor is anyone diagnosed with cancer)?
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| Yes
No |
If you are not a cancer survivor, what is your relationship?
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Caregiver
Spouse
Parent
Other relative
Friend
Professional
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If you are a healthcare professional, please indicate your degree and place of work:(255 char. max)
Degree (eg, RN, MD, MSW): Place of work (eg, hospital, community clinic, private practice, etc.):
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| 2. What is your age? |
under 18
18 to 25
26 to 30
31 to 40
41 to 50
51 to 60 61 to 70
71 or older
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3. What is your gender?
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| Male
Female |
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4. If you are a cancer survivor, how long has it been since you were diagnosed?
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N/A
Less than 30 days
1–3 months
4–7 months
8–11 months
1–3 years
4–7 years
8–10 years
11–20 years
More than 20 years
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| 5. What treatments have been used? |
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6. Are you (or the survivor) currently in, currently considering, or have participated in a clinical trial?
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Currently in a clinical trial
Considering participation in a clinical trial Have participated in a clinical trial No N/A |
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7. Have you (or the survivor) discussed a clinical trial with your (or the survivor’s) physician?
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| Yes
No
N/A |
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| 8. Please give us your feedback on the presentations. Select 1 answer for each. |
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9. If you had access to this information at the time of diagnosis or during treatment, would it have changed the way you managed your (or the survivor’s) disease?
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| Yes
No
N/A |
If so, how? (255 char. max)
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10. Having completed this program, do you feel more prepared to discuss your (or the survivor's) treatment management plan with your/their healthcare team?
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| Yes
No N/A |
If so, how? (255 char. max)
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11. Do you feel this program will help you (or the survivor) cope with the challenges related to the disease?
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| Yes
No N/A |
If so, how? (255 char. max)
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12. Overall, how helpful was this program?
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| Not helpful at all Somewhat helpful
Helpful
Very helpful |
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13. What can we do to improve this program? (255 char. max)
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| 14. How did you hear about this program? |
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15. Other comments: (255 char. max)
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Thank you for your feedback.
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