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Abnormalities of the Immune System in Cancer Patients
1.
I attended this web program as a: (select one).
Patient
Caregiver
Family Member
Friend/Concerned Individual
Healthcare Professional
Community Member
LLS Staff
LLS Volunteer
Other (please specify)
2.
What is your race or ethnicity?
Asian
Black or African American
Hispanic or Latino
American Indian or Alaskan Native
Native Hawaiian or other Pacific Islander
White
Prefer not to disclose
3.
Are you Hispanic/Latino/a/x?
Yes
No
4.
What is your date of birth?
(MM/DD/YYYY)
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
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22
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31
5.
Do you describe yourself as a man, a woman, or in some other way?
A Man
A Woman
Prefer not to answer
In some other way (with open text field)
6.
In what ZIP/Postal code is your home located?
7.
Have you or the patient been diagnosed with a blood cancer?
Yes
No
N/A
If no, please tell us the type of cancer with which you/patient were diagnosed:
8.
If yes, when were you/patient diagnosed? (MM/DD/YYYY):
9.
If yes, please tell us what type of blood cancer (check all that apply):
Non-Hodgkin lymphoma (NHL)
Mantle cell lymphoma (MCL)
Hodgkin lymphoma (HL)
Chronic lymphocytic leukemia (CLL)
Chronic myeloid leukemia (CML)
Acute lymphoblastic leukemia (ALL)
Acute myeloid leukemia (AML)
Myelodysplastic syndromes
Myeloproliferative neoplasms (MPN) (polycythemia vera, essential thrombocythemia, myelofibrosis)
Multiple myeloma
Other (please specify)
10.
Are you or the patient currently being treated?
Yes
No
11.
What treatments have you or the patient had? (check all that apply):
Combination drug therapy (chemotherapy)
Single Drug Therapy
Allogeneic stem cell transplant (donor)
Autologous stem cell transplant
CAR T- cell Therapy
Radiation therapy
Immunotherapy
Blood transfusions
Watch & Wait
N/A
Other (please specify)
12.
Are you presently in or have you ever participated in a clinical trial?
Yes
No
N/A
13.
Is there a COVID-19 treatment/prophylaxis that you would like to find out more about?
14.
Please check true or false. As a result of this program
True
False
I learned about infectious complications in patients with blood cancers with a focus on abnormalities in the immune system.
True
False
I learned about the current standard of practice to decrease infectious complications in patients with blood cancers.
True
False
I learned about special considerations for blood cancer patients regarding the COVID-19 pandemic.
True
False
15.
Which form(s) of cancer education do you most prefer?
Webcasts (live or pre-recorded)
Short videos
Podcasts
Booklets
Other (please specify)
16.
Please describe any information you expected to get from this program but did not receive.
17.
Please give us any additional feedback about this program.
