THE PINK FUND 2018 SURVEY

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* 1. What was your age at diagnosis?

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* 2. What was the stage of your diagnosis?

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* 3. Number of years post treatment:

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* 4. How did you pay for your breast cancer treatment (check all that apply)

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* 5. What percentage of your treatment costs was covered by your insurance?

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* 6. How much money did you pay out of pocket for treatment? (Include deductibles, copay, and alternative treatments)

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* 7. Were you employed when you received your diagnosis?

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* 8. If you were employed at diagnosis, were you able to work through treatment?

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* 9. How did your cancer diagnosis affect your career?

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* 10. Has your income decreased since your diagnosis?

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* 11. If your income has decreased, how much has your income decreased?

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* 12. Have you applied for state or federal disability insurance due to your diagnosis?

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* 13. If you applied for state or federal disability insurance, were you approved or denied?

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* 14. Have you applied for and/or received bill payment assistance since your diagnosis?

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* 15. If yes, how long did you receive assistance?

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* 16. What kind of financial hardship did you experience due to treatment? (Check all that apply)

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* 17. Are you still living in the same home you were in at the time of your diagnosis?

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* 18. If you are still living in the same home, did you have to refinance, or receive rental or mortgage assistance, in order to stay?

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* 19. If you moved, did you move due to financial reasons?

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* 20. Did your move involve moving in with family? (check all that apply)

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