Sexuality & Young Adult Cancer: What you need to know Survey

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

Patient

Caregiver

Family Member

Friend/Concerned Individual

Healthcare Professional

Community Member

LLS Staff

Volunteer

Other (please specify)

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* 2. What is your race or ethnicity?

Asian

Black or African American

Hispanic or Latino

Native American or Alaska Native

Native Hawaiian or other Pacific Islander

White

Another race or ethnicity, please describe below

Prefer not to disclose

Self-describe below:

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* 3. What is your date of birth?

(MM/DD/YYYY)

Date

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* 4. What is your gender?

Female

Male

Prefer not to disclose

Other (please specify)

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* 5. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

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

Yes

N/A

If no, please tell us the type of cancer with which you/patient were diagnosed:

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* 7. If yes, when were you/patient diagnosed? (MM/DD/YYYY):

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

Acute lymphoblastic leukemia (ALL)

Acute myeloid leukemia (AML)

Chronic lymphocytic leukemia (CLL)

Chronic myeloid leukemia (CML)

Hodgkin lymphoma (HL)

Mantle cell lymphoma (MCL)

Myelodysplastic syndromes

Multiple myeloma

Myeloproliferative neoplasms (MPN) (polycythemia vera, essential thrombocythemia, myelofibrosis)

Non-Hodgkin lymphoma (NHL)

Other (please specify)

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

Yes

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

CAR-T

Single Drug Therapy

Allogeneic stem cell transplant (donor)

Autologous stem cell transplant

Combination drug therapy (chemotherapy)

Treatment Cessation

Radiation therapy

Immunotherapy

Blood transfusions

N/A

Other (please specify)

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

Yes

N/A

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

Webcasts (live or pre-recorded)

Short videos

Podcasts

Booklets

Other (please specify)

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* 13. Following this program, do you feel that a cancer diagnosis can cause an interruption in forming your sexual identity and/or developing romantic/ sexual relationships?

Yes

N/A

Sexuality & Young Adult Cancer: What you need to know

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

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* 2. What is your race or ethnicity?

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* 3. What is your date of birth?

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* 4. What is your gender?

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* 5. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 00544 or 94305)

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

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* 7. If yes, when were you/patient diagnosed? (MM/DD/YYYY):

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

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

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

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

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

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* 13. Following this program, do you feel that a cancer diagnosis can cause an interruption in forming your sexual identity and/or developing romantic/ sexual relationships?

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* 14. If yes, how?

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

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* 16. What other young adult topics would you like LLS to address?

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