Parenthood While in Hematology: Perceived Barriers Survey

Participant Information

Please utilize the previous and next button options (at the end of each page) to save your progress as you participate in our survey.

Question Title

* 1. What is your age?

18-24

25-34

35-44

45-54

55+

Question Title

* 2. Which category best describes? Please select all that apply:

Native American or Alaskan

Asian

Black or African American

Caucasian or White

Hispanic, Latino or of Spanish Origin

Multiethnic

Prefer Not To Disclose

Other

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* 3. What is your gender?

Female

Male

Transgender

Prefer Not To Disclose

Other (specify)

Question Title

* 4. Which of the following best describes your current relationship status?

Married

Widowed

Divorced/Separated

Cohabiting with a significant other or in a domestic partnership

Single, never married

Prefer not to answer

Question Title

* 5. Are/were you the primary childcare provider within your household?

Yes

Other (please specify)

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* 6. What is your current position title?

Trainee

Junior Attending

Established Attending

Other (please specify)

Parenthood While in Hematology: Perceived Barriers Survey

Participant Information

Question Title

* 1. What is your age?

Question Title

* 2. Which category best describes? Please select all that apply:

Question Title

* 3. What is your gender?

Question Title

* 4. Which of the following best describes your current relationship status?

Question Title

* 5. Are/were you the primary childcare provider within your household?

Question Title

* 6. What is your current position title?

Question Title

* 7. What setting do you currently work in?

Question Title

* 8. In what state or U.S. territory do you live?