Patient Impact Survey

Your feedback helps the UCA determine the best ways to support patients.

Choose One

Patient

Family of Patient

First name

Last name

Email

Yes, subscribe me to your newsletter.

Phone

Address

Cancer Diagnosis

Doctor/Cancer Facility

How often did these needs cause stress or worry during treatment?

Very much

Somewhat

A little

Not at all

Did the UCA's assistance help you address these needs?

Very much

Somewhat

A little

Not at all

Assistance Impact on Treatment

Before assistance from the UCA, did you or a family member ever have to: (Select all that apply)

Skip meals or other essentials to pay medical expenses

Cancel or reschedule due to lack of transportation

Delay picking up medication or skip medication

Delay scheduling a doctor's appointment

Consider postponing imaging or testing

Miss a treatment or infusion

None of the above

Did UCA’s support help during treatment?

Yes

No

Did UCA’s support help you or a family member make appointments you might have missed?

Yes

No

Did UCA fill a gap in support that was not otherwise available to you or a family member?

Yes

No

Did you ever worry that you or a family member might not be able to complete treatment due to financial or life circumstances?

Yes, definitely

Yes, sometime

No

Unsure/Prefer not to say

Because of UCA’s support, it was easier for myself or a family member to follow a treatment plan:

Thoughts from Your Experience

In your opinion, should cancer patients have access to support from an organization like UCA as part of their standard care?

Yes

No

In your own words, how did UCA support you or your family during treatment?

Is there anything you want funders or healthcare partners to know about the impact of UCA’s support?

May we share your comments (with your permission and with identifying details removed)?

Yes

No