CH Survey COVID-19

Dealing With COVID-19
The COVID-19 pandemic has changed how we live, work and access health care. Cancer Health wants to know how the novel coronavirus has affected you and your health.
1) How concerned are you about contracting the novel coronavirus?

Very concernedSomewhat concernedNot at all concernedI tested positive for the coronavirus.
2) How much have you been affected by the COVID-19 pandemic?

Severely affectedModerately affectedSlightly affectedNot at all affected
3) Do you have an emergency supply of any medication you take?

YesNoI don’t take any medication.
4) Did you lose your job or any income because of the COVID-19 pandemic?

YesNo
5) Did you lose your health insurance because of the COVID-19 pandemic?

YesNo
6) Have you used telemedicine to connect to a health care provider during the COVID-19 pandemic?

YesNo
7) Have you encountered an interruption of any of your cancer treatments?

YesNoI'm not undergoing any treatment for cancer.
8) Have you encountered an interruption of any other cancer services or support?

YesNoI'm not using any other cancer cervices or support.
9) Have you encountered an interruption of any of your health care services?

YesNo
10) How have you been connecting with others during the COVID-19 pandemic? (Check all that apply.)

EmailIn personSocial mediaTelephoneTextsVideoconferencingOther
11) Which of the following are you doing to take care of your mental health during the COVID-19 pandemic? (Check all that apply.)

Taking breaks from the news and social mediaGetting regular exerciseEating healthy, well-balanced mealsGetting plenty of sleepAvoiding alcohol and drugsConnecting with othersMeditating/finding space to relaxNone of the aboveOther
12) How would you rate the federal government’s response to the COVID-19 pandemic?

ExcellentGoodFairPoor
13) How would you rate your local government’s response to the COVID-19 pandemic?

ExcellentGoodFairPoor
14) What year were you born?
15) What is your gender?

MaleFemaleTransgenderOther
16) What is your sexual orientation?

StraightGay/LesbianBisexualOther
17) What is your ethnicity? (Check all that apply.)

American Indian or Alaska NativeArab or Middle EasternAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderWhiteOther
18) What is your current level of education?

Some high schoolHigh school graduateSome collegeBachelor’s degree or higher
19) What is your household income?

Under $15,000$15,000 - $34,999$35,000 - $49,999$50,000 - $74,999$75,000 - $99,999$100,000 and over
20) What is your zip code?
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Dealing With COVID-19