Check the box to confirm that you understand how survey results will be used.
* must provide value
Would you like to be entered into a $50 gift card drawing for participating in this survey?
Yes
No
Would you be interested in participating in a discussion group to share more about your cancer experience?
Yes
No
Please enter your first and last name, phone number, and current e-mail address. Please note that by providing your contact information, your responses will no longer be anonymous.
What county do you currently reside in?
* must provide value
Alexander Anson Burke Cabarrus Caldwell Catawba Cleveland Davidson Dave Forsyth Gaston Guilford Iredell Lincoln Mecklenburg Randolph Rockingham Rowan Rutherford Stanly Stokes Surry Union Watauga Wilkes Yadkin Chester Chesterfield Lancaster York Other
What other county do you reside in?
Have you ever been diagnosed as having cancer?
* must provide value
Yes
No
Did you receive a cancer diagnosis between the ages of 13-39?
* must provide value
Yes
No
What type of cancer were you diagnosed with?
* must provide value
What other type of cancer were you diagnosed with?
At what age were you first told you had cancer?
* must provide value
13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 Prefer not to say
What is your current age?
* must provide value
13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Prefer not to say
Please specify where you received or are receiving treatment. Mark all that apply.
* must provide value
What type of cancer care did you receive at Wake Forest Baptist Brenner Children's Hospital? Mark all that apply.
What type of cancer care did you receive at Wake Forest Baptist Comprehensive Cancer Center? Mark all that apply.
What type of cancer care did you receive at Atrium Health Levine Cancer Institute? Mark all that apply.
What type of cancer care did you receive at Atrium Health Levine Children's Hospital? Mark all that apply.
What other location/s are you currently or have previously received ongoing treatment for your cancer?
Have you ever received any of the following treatments for your cancer? Mark all that apply.
* must provide value
What other types of treatment have you received for your cancer?
Did a healthcare professional involved in your cancer care talk with you about options to preserve your fertility (e.g., sperm banking or freezing of eggs, embryos, or ovarian tissue) before you started cancer treatment?
* must provide value
Yes
No
I don't know
Prefer not to say
Which healthcare provider spoke with you about options about preserving your fertility (e.g., sperm banking or freezing of eggs, embryos, or ovarian tissue) before you started cancer treatment?
* must provide value
Doctor
Nurse or Physician Assistant
Social Worker
Patient Navigator
Other
Prefer not to say
What other healthcare provider spoke with you about preserving your fertility?
Did you decide to undergo any type of fertility preservation?
* must provide value
Yes
No
Why did you NOT decide to undergo fertility preservation? Mark all that apply.
What was the other reason why you did not undergo with fertility preservation?
Clinical trials are research studies that involve people and include surgery, radiation, chemotherapy, drugs, or other treatments. Clinical trials are sometimes also called experimental studies or protocols. Have you ever heard of a clinical trial?
* must provide value
Yes
No
Don't know
Prefer not to say
DId you participate in a research study or clinical trial as part of your cancer treatment?
* must provide value
Yes
No
Don't know
Prefer not to say
I don't know
Below is a list of possible reasons that people do not participate in clinical trials. For each of the following, please
* must provide value
Your doctor never recommended a clinical trial to you
You did not think that a clinical trial would help you
You were worried about side-effects of the treatment in the clinical trial
You were too sick to have treatment in a clinical trial
Your insurance would not cover part or all of the payment for the clinical trial
You were worried that you might get a placebo or sugar pill rather than actual treatment
You were worried that you might be treated like a guinea pig
You were worried that you might receive treatment that had not been sufficiently tested
You were worried that you would have to switch doctors in order to participate in the clinical trial
You could not find a trial that was near you
There were no clinical trials available for your type and stage of cancer at the time of your treatment
Other
Prefer not to say
I don't know
What were other reasons you did not participate in a clinical trial?
Since being diagnosed with cancer, which of the following health-related topics have you learned about? Mark all that apply.
* must provide value
What other topics were you interested in learning about after being diagnosed with cancer?
After you were diagnosed with cancer, did your doctor, nurse, or other health professional talk with you about how cancer may affect your emotions or your relationships with other people?
* must provide value
Yes
No
Don't know
Prefer not to say
After your cancer diagnosis, did you receive professional counseling or join a support group to help you cope?
* must provide value
Yes
No
Don't know
Prefer not to say
If not, what was the MAIN reason you did not get professional counseling or join a support group?
I didn't know these services were available
I didn't want it
I didn't think I needed it
I couldn't afford it
Refused
Some other reason
Don't know
What was the other reason you did not get professional counseling or join a support group?
How much has cancer caused financial problems for you and your family?
* must provide value
A lot
Some
A little
Not at all
I don't know
Prefer not to say
What could have or would make you feel more comfortable when receiving cancer treatment?
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Please check off the following support areas that are important to you. Mark all that apply.
* must provide value
What other support areas are of importance to you?
Are you currently in active treatment now? (Active treatment is primary treatment to cure cancer, and doesn't include long-term treatment, [i.e. hormonal therapy] to lessen the chance of cancer coming back)
* must provide value
Yes
No, treatment has not started yet
No, I have finished treatment
Don't know
Prefer not to say
How long has it been since your treatment ended?
Less than 6 months
More than 6 months, but less than 2 years
Greater than 2 years
Nearing the end of your treatment, what information/resources were you provided to help you navigate your transition into survivorship? (ex: support resources, educational material) Mark all that apply.
* must provide value
What were other support resources provided to you?
Were you and your provider able to establish a primary care provider (PCP) to follow you after your treatment?
* must provide value
Yes
No
I already had a PCP established
I don't know
Prefer not to say
A survivorship care plan (SCP) is a document that includes a summary of your cancer treatment and recommendations for follow-up care and staying healthy. Following completion of your active treatment for cancer, did you receive an SCP from your nurse or doctor?
* must provide value
Yes
No
I don't know
Prefer not to say
Where do you receive your cancer follow-up care? Mark all that apply.
* must provide value
I feel that I was well educated and prepared for life after my cancer treatment.
* must provide value
Strongly agree
Somewhat agree
Neither agree nor disagree
Somewhat disagree
Strongly disagree
I don't know
Prefer not to say
What type of events and programs interest you? Mark all that apply.
* must provide value
What other event or programs interest you?
It has been noted that people do not participate in activities for the reasons below. Please check all those that apply to you.
* must provide value
What other things would keep me from taking part in activities and events?
What educational topics would be of interest to you? Mark all that apply.
* must provide value
In what ways would you be interested in connecting with others around the same age as you who have also had cancer? Mark all that apply.
* must provide value
What other types of events and programs interest you?
How often would you be interested in attending events and programs?
* must provide value
Weekly
Twice per month
Once per month
Quarterly
Yearly
I am not interested in attending events and programs
I don't know
Prefer not to say
How would you prefer to learn about AYA information, events and future programs? Mark all that apply.
* must provide value
What other ways would you like to receive information about future programs?
Are you of Hispanic, Latino/a, or Spanish origin?
Yes
No
What is your race? One or more categories may be selected. Mark all that apply.
What is your gender? Mark only one.
Male
Female
Transgender Male (Female-to-Male)
Transgender Female (Male-to-Female)
Non-Binary
Other
Prefer not to answer
Do you think of yourself as?
Straight/Heterosexual
Bisexual
Pansexual
Lesbian
Gay
Not sure/questioning
Other
Prefer not to answer
