1.Age

18-24

25-34

35-44

45-54

55-64

65+

2.Ethnic group you identify with:

White

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other (please specify)

3.What is your gender?

4.Type of cancer diagnosis OR please let us know your role if you are not a patient:

5.Please check all of the in-person support groups that you would have interest in attending:

Breast Cancer (In-Person)

Ovarian Cancer

Prostate Cancer

Lung Cancer

Memory & Cognition (related to cancer treatment)

Post-Treatment Survivorship (In-Person)

Other (please specify)

6.Would you have interest in one-on-one peer support from an individual that has had a similar cancer diagnosis as you?

Yes

No

7.How likely are you to attend an in-person support group that focuses on coping with parenting and/or managing professional responsibilities while undergoing cancer treatment regardless of diagnosis?

Very likely

Likely

Unlikely

Very unlikely

8.Are there any groups, services, or activities that you would like to see Canopy offer that are not currently offered?

9.What factors make it difficult for you to attend a group or class at Canopy?

Uncomfortable with group settings

Concerned that group members may not be similar to me

The need to arrange for childcare

Cost of transportation to and from Canopy

Groups are not offered at times that work for my schedule

Other (please specify)

10.Is there anything Canopy can do to address any of these factors to increase your likelihood of being able to attend a group or class?