Cancer Health_Spring_2022

Are You Prepared?

It’s important to have a plan in place in case of an emergency. Depending on the situation, it may be difficult to get the cancer care you need. Please take our survey and let Cancer Health know how prepared you are in the event of a disaster.
In general, how prepared are you to handle an emergency situation?

I’m ready for anything.I’m somewhat prepared.I’m not at all prepared.
Do you keep an emergency supply of all the medications that you take?

YesNo
Do you keep an emergency supply of food and water in your home?

YesNo
Do you keep a well-stocked and up-to-date first aid kit in your home?

YesNo
Do you have an evacuation action plan in case of an emergency?

YesNo
Have you shared your emergency plans with others?

YesNo
Do you keep your emergency gear packed in an easy-to-carry bag or container?

YesNo
Do you keep up-to-date hard copies of your medical and financial records in a safe place?

YesNo
Do you keep up-to-date electronic copies of your medical and financial information?

YesNo
Do you keep a copy of important phone numbers and passwords in a safe place?
Do you have a will?

YesNo
Do you have an advance health care directive?

YesNo
What year were you born?
What is your gender?

MaleFemaleTransgenderOther
What is your current level of education?

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

Less than $15,000$15,000–$34,999$35,000–$49,999$50,000–$74,999$75,000–$99,999$100,000 or more
What is your ethnicity? (Check all that apply.)

American Indian/Alaska NativeArab/Middle EasternAsianBlack/African AmericanHispanic/LatinoNative Hawaiian/Pacific IslanderWhiteOther
What is your ZIP code?
Please verify that you are human*
Should be Empty:

Are You Prepared?