Section 1: Demographic Information

This survey is designed to assess the needs of cancer caregivers in our community. All responses will remain confidential. Instructions are provided at the top of each section. If you wish to change any of your responses, you can return to earlier portions of the survey by pressing the Prev button at the bottom of a section.

All participants complete Section 1. At the end of Section 1, you will taken to Section 2 if you are a current cancer caregiver, or Section 3 if you are a past caregiver. The survey will take you to the correct section when you press the Next button at the end of the section.

Approximate time to complete: 10 minutes


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* 1. What is your age?

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* 2. What is your gender?

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* 3. What is your marital status?

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* 4. What is your current ZIP Code?

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* 5. What is the highest level of education you have completed?

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* 6. What is your approximate current household income?

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* 7. What language do you mainly speak at home?

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* 8. What is your ethnicity? (Please select all that apply.)

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* 9. What is/was the diagnosis of the patient for whom you acted/are acting as a caregiver?

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* 10. What is your relationship to the patient for whom you are/were a caregiver?

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* 11. Are you currently acting as a caregiver for a cancer patient?

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