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* 1. Are you a cancer patient or a caregiver for a cancer patient?

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* 2. What is the cancer diagnosis?

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* 3. What is your age range?

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* 4. What is your sex?

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* 5. What is your race?

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* 6. What is your education level?

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* 7. What is your household income (in US dollars)?

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* 8. Please indicate where you received or plan to receive the majority of your cancer treatment by selecting one of the following options:

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* 9. How far, in miles, did you have to travel to receive care for your cancer?

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* 10. Please RATE the difficulty of each of the following  (0=Not challenging; 4=Extremely challenging). 

  0 (Not at all challenging) 1 2 (Somewhat challenging) 3 4 (Extremely challenging)
Financial stress
Legal stress
Work or return-to-work related stress
Stress related to treatment, treatment toxicity or complications
Stress related to medical conditions or cancer symptoms
Local transportation-related stress
Family care stress
Emotional stress
Long distance travel-related stress
Insurance-related stress
Family coping/stress

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* 11. Please select the FIVE most difficult:

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* 12. Please RATE the difficulty of each of the following (0=Not challenging; 4=Extremely challenging). 

  0 (Not at all challenging) 1 2 (Somewhat challenging) 3 4 (Extremely challenging)
Understanding cancer diagnosis and treatment plan
Receiving regularly scheduled follow-up communication
Coordination of care among your treatment team (ie Surgical Oncologist, Medical Oncologist, Radiation Oncologist, etc.)
Transferring records or results between organizations

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* 13. Please RANK the difficulty of each of the following (1=Most challenging; 4=Least challenging). 

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* 14. In the past 4 weeks, have you had problems transferring your medical information, records?

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* 15. In the past 4 weeks, have you experienced any challenges related to transportation that hindered your ability to fully complete aspects of your cancer care?

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* 16. In the past 4 weeks, have you experienced any financial difficulties that impacted your ability to fully participate in your cancer treatment?

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* 17. In the past 4 weeks, have you experienced any emotional or psychological distress that affected your ability to fully participate in your cancer care and treatment?

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* 18. In the past 4 weeks, have you felt that there was a lack of coordination between your cancer care and treatment teams that impacted your ability to receive proper care?

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* 19. Is there anything else you’d like us to know?

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