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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)
Work or return-to-work related stress
Stress related to medical conditions or cancer symptoms
Financial stress
Stress related to treatment, treatment toxicity or complications
Legal stress
Insurance-related stress
Family care stress
Local transportation-related stress
Family coping/stress
Emotional stress
Long distance travel-related 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
Coordination of care among your treatment team (ie Surgical Oncologist, Medical Oncologist, Radiation Oncologist, etc.)
Transferring records or results between organizations
Receiving regularly scheduled follow-up communication

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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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