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Survey of Cancer Survivors
1. General Information
1 / 8
1
. Gender
Gender
Female
Male
2
. Age(in years)?
0-4
5-9
10-14
15-19
20-24
25-29
30-39
40-49
50-59
60-69
70-79
80-89
90+
At time of first diagnosis
Age(in years)? At time of first diagnosis 0-4
5-9
10-14
15-19
20-24
25-29
30-39
40-49
50-59
60-69
70-79
80-89
90+
Today
Today 0-4
5-9
10-14
15-19
20-24
25-29
30-39
40-49
50-59
60-69
70-79
80-89
90+
3
. In what state do you live?
In what state do you live?
State:
-- select state --
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
4
. Marital Status
Married
Single
When first diagnosed with cancer
Marital Status When first diagnosed with cancer Married
Single
Now
Now Married
Single
5
. Race
Race
American Indian
Asian
Black
Hispanic
White
Multi-racial
Prefer not to answer
6
. What is the highest level of your education?
What is the highest level of your education?
Some high school
High school graduate
Some college
Degree from a two-year college
Degree from a four-year college
Graduate degree
7
. Household Income
Household Income
Less than $50,000
$50,000-100,000
$100,000-$150,000
$150,000-$200,000
Greater than $200,000
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