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* 1. I attended this web program as a: (select one).

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* 2. What is your race or ethnicity?

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* 3. Are you Hispanic/Latino/a/x?

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* 4. What is your date of birth? (LLS is unable to correspond with minors.)

Date

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* 5. Do you describe yourself as a man, a woman, or in some other way?

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* 6. In what ZIP/Postal code is your home located? 

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* 7. Have you or the patient been diagnosed with a blood cancer?

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* 8. If yes, when were you/patient diagnosed? 

Date

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* 9. If yes, please tell us what type of blood cancer (check all that apply):

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* 10. Are you or the patient currently being treated?

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* 11. What treatments have you or the patient had? (check all that apply):

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* 12. Are you presently in or have you ever participated in a clinical trial?

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* 13. As a result of participating in this program, to what extent do you agree to the following statements? (Select one answer for each)

  Strongly Disagree Disagree Agree Strongly Agree N/A
I am knowledgeable of which blood cancers benefit from CAR T-cell therapy.
I  know when to discuss CAR T-cell therapy with my doctor.
I know the factors to consider regarding CAR T-cell therapy for older adults .
I  know the potential side effects of CAR T-cell therapy.

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* 14. Following this program, do you feel more prepared to discuss CAR T-cell therapy with your healthcare team?

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* 15. Which form(s) of cancer education do you most prefer?

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* 16. Please describe any information you expected to get from this program but did not receive.

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* 17. Please give us any additional feedback about this program.

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