CRP Social Determinants of Health Survey

The ACS Cancer Research Program is looking for sites to participate in a pilot survey measuring social determinants of health across CoC facilities. Please complete the survey below if you are interested in participating and providing your feedback.

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* 1. Name

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* 2. Email Address

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* 3. Institution Name

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* 4. Is your institution CoC accredited?

Yes

Don't know

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* 5. If yes, type of CoC Accredited facility:

Academic Comprehensive Cancer Program (ACAD)

Community Cancer Program (CCP)

Comprehensive Community Cancer Program (CCCP)

Free Standing Cancer Center Program (FCCP)

Hospital Associate Cancer Program (HACP)

Integrated Network Cancer Program (INCP)

NCI- Designated Comprehensive Cancer Center Program (NCIP)

NCI- Designated Network Cancer Program (NCIN)

Pediatric Cancer Program (PCP)

Veterans Affairs Cancer Program (VACP)

N/A

Don't know

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* 6. Which of the following best describes your current facility location?

Urban

Suburban

Rural

Other (please specify)

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* 7. In which geographical region is your facility?

Northeast

Midwest

South

West

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* 8. Does your facility serve a large population of members of a minoritized racial or ethnic group?

Yes

N/A

Other (please specify)

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* 9. Does your facility serve a large population of uninsured or under insured patients

Yes

N/A

Other (please specify)