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Breast Cancer and COVID-19 Ongoing Survey
1.
Are you a:
Breast cancer patient/survivor
Caregiver
Other (please specify)
2.
What stage is/was your diagnosis?
Newly diagnosed (not yet staged)
DCIS, Stage 1, Stage 2, or Stage 3
Stage 4/metastatic
N/A
3.
What year were you diagnosed?
4.
If you are a breast cancer patient/survivor, are you in active treatment at this time?
Please choose the option that best describes your current treatment status.
Yes (treatment pending from recent diagnosis)
Yes (oral treatment only)
Yes (regular infusions or chemotherapy)
Yes (radiation)
Yes (recent or upcoming surgery)
No
Other (please specify)
5.
Have you experienced any of the following challenges accessing care for your breast cancer care/treatment?
Select all that apply.
Delays in getting in to/reaching doctor
Routine blood tests canceled/postponed
Imaging/Scans canceled/postponed
Radiation treatment canceled/postponed
Follow-up visits with doctor canceled/postponed
Breast cancer surgery canceled/postponed
Reconstruction surgery canceled/postponed
Infusions/chemotherapy canceled/postponed
Having to have virtual visits instead of in-person
Getting medications
Not seeking needed treatment because I am worried about exposure to the coronavirus
Not yet - my appointments are in the future and not yet impacted
Other (please specify)
6.
If your breast cancer treatment/care has been delayed, please describe by how long your care has been delayed below:
Weeks:
Months:
Other:
7.
As a caregiver of someone with breast cancer, have you experienced challenges accessing breast cancer services/resources for the person you are caring for?
Yes
No
N/A
If yes, please explain.
8.
If you are presently in treatment, has your medical provider or healthcare system contacted you directly to provide medical advice on how to protect yourself against COVID-19 or access care should you have symptoms?
Yes
No
N/A
If yes, please explain:
9.
Was the information they provided helpful or satisfactory?
Extremely helpful
Very helpful
Somewhat helpful
Not so helpful
Not at all helpful
10.
Have you experienced symptoms, and have you reached out for COVID-19 testing and been denied access?
Yes
No
N/A
If yes, please explain:
11.
Do you have insurance or payment concerns related to your care and treatment should you be diagnosed with COVID 19?
Yes
No
N/A
If yes, please explain.
12.
Are there other challenges as a result of the pandemic you have experienced as a breast cancer patient or caregiver you’d like to share with NBCC?
13.
Have you previously completed and submitted this survey over the last 6 weeks?
Yes
No
*
14.
What state are you located in?
(Required.)
15.
If you are willing, please share your name and contact information.
Name
Email Address
Phone Number
