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Cancer Survivor Survey Program Year 4

Survivors of cancer sometimes experience different needs than those of the general community. Your responses to the following questions will help the SPIPA Health & Wellness programs better tailor the support services and information available to cancer survivors within your community. Your feedback is valuable.  We would like to thank you for taking the time to complete this survey by providing you with a $25 gift card in support of your survivorship needs. Your personal information will be maintained with strict confidentiality and will not be shared outside the South Puget Intertribal Planning Agency's (SPIPA's) Health & Wellness Programs team. 

This survey was supported by grant funding from the Centers for Disease Control and Prevention. Contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.
 
1.Contact Information.  Only cancer survivors who complete this survey are eligible to receive a $25 gift card to support survivorship needs.  Gift cards for eligible respondents will be mailed to the address provided here.
2.Have you ever been diagnosed with cancer?(Required.)
3.Tell us about your cancer:(Required.)
4.Where are/were you seen for your cancer treatment?
5.Are you still receiving cancer treatments?
6.If it has been 5 or more years since you completed your cancer treatment, have you returned to receiving care with your primary care provider?
7.Would you say that in general your health is:
8.What type of health/wellness care have you used in your cancer journey? (check all that apply)
9.Do you have one person you think of as your personal doctor or health care provider?
10.Have any of the following kept you from medical care in the past 12 months? (check all that apply)
11.Tell us about challenges you face as a cancer survivor:
Disagree Strongly
Disagree a little
Agree a little
Agree strongly
I feel emotionally overwhelmed
I feel physically overwhelmed
I feel like I am a burden to my family/caregivers
I have discomfort/pain due to cancer treatment
I have financial problems due to cancer
I feel I have a lack of support from family/friends
I feel I lack ongoing support from my tribe/community
I do not understand what my care options are
I am unclear about what follow-up care I need
I am unsure when to see my primary doctor instead of my oncologist
12.What would assist you as a cancer survivor?
Disagree strongly
Disagree a little
Agree a little
Agree strongly
N/A
Cancer support group
Gas/food cards while going through treatment
A person to call if you have questions about cancer
Staying healthy after treatment - classes, information
information on insurance, disability and financial issues
Cancer awareness walk
Culturally appropriate handouts
digital story - capturing your story on video/photos/audio
13.How can we best support someone who has been newly diagnosed?
14.How can we best support a cancer survivor to stay healthy?
15.Do you currently use any of the following tobacco or related products?
None
A couple times per week
1 time per day
2-5 times per day
6-9 times per day
10-19 times per day
20 or more a day (pack)
Traditional tobacco
Smoking tobacco
Chewing tobacco
E-cigarette or vape
Medicinal marijuana
Recreational marijuana
16.How long has it been since you last:
Less than 1 year
1 - 2 years
2 - 3 years
3 - 4 years
4 - 5 years
More than 5 years
Never
N/A
Visited a doctor, nurse, or other health professional for a routine checkup
Had a colonoscopy
Had a doctor, nurse, or other health professional check you for skin cancer
Had a mammogram (If male, select N/A)
Had a cervical exam/PAP (If male, select N/A)
Had a CT scan to assess for lung cancer
17.Is there anything else you'd like to share with us about your cancer journey?
18.Would you like to share the story of your cancer journey with others in your community?
19.Which SPIPA Tribal Community are you a member of?(Required.)
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