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Reducing the Burden of Cancer
Survey -- May 2012
The Val Verde-Kinney Cancer Task Force wants to reduce the burden of cancer for you and your loved ones.  Your thoughts will help us decide on our next steps.  Thank you for taking a few minutes to complete this short survey.

1.
In which county do you live?
Val Verde
Kinney
2.
What is your gender?
Female
Male
3.
What is your age?
Under 25
25 to 34
35 to 44
45 to 54
55 to 64
65+
4.
Are you covered by health insurance?  Please select all that apply:
Yes, general health
Yes, Medicaid
No, I do not have health insurance.
Yes, a cancer policy
Yes, Medicare

5.
Have you had direct experience with cancer? Please select all that apply:
Yes, I am a cancer survivor.
Yes, family members have had cancer.
Yes, a friend or co-worker had cancer.
Yes, I am or was a caregiver for someone with cancer.
Yes, I am a health care professional who works with cancer patients.
Yes, I am a social services provider who works with cancer patients.
No, I have not had any direct experience with cancer.


6.
IMPORTANCE:  On a scale of 5 to 1 (5=Very important and 1=Not important at all)
please rate HOW IMPORTANT each of the following ideas to reduce the burden of cancer is to YOU and YOUR FAMILY.
5
4
3
2
1
a.
Central location with staff members to provide cancer information and referral services
b.
More education on cancer prevention and screening tests for cancer
c.
Cancer support groups for everyone affected by cancer
d.
Financial assistance for transportation, treatment, and related expenses
e.
Low-cost and/or free screening tests for cancer
f.
Sidewalks, hiking/biking trails, fitness centers, physical fitness contests
g.
Farmers' markets, organic foods, healthier food choices in restaurants
h.
Employer wellness program to recognize employee healthy behavior practices

7.
EFFECTIVENESS:  On a scale of 5 to 1 (5=Big difference and 1=No difference at all),
please rate HOW MUCH OF A POSITIVE DIFFERENCE each of the following ideas will make to reduce the burden of cancer in the COMMUNITY.
5
4
3
2
1
a.
Central location with staff members to provide cancer information and referral services
b.
More education on cancer prevention and screening tests for cancer
c.
Cancer support groups for everyone affected by cancer
d.
Financial assistance for transportation, treatment, and related expenses
e.
Low-cost and/or free screening tests for cancer
f.
Sidewalks, hiking/biking trails, fitness centers, physical fitness contests
g.
Farmers' markets, organic foods, healthier food choices in restaurants
h.
Employer wellness program to recognize employee healthy behavior practices


8.
SELECTION: If the Val Verde-Kinney Cancer Task Force could only focus on THREE (3) of the following ideas this year, which THREE (3) of the eight presented (a, b, c, d, e, f, g, h) would be your 1st, 2nd, and 3rd choices.

a. Central location with staff members to provide cancer information and referral services.
b. More education on cancer prevention and screening tests for cancer.
c. Cancer support groups for everyone affected by cancer.
d. Financial assistance for transportation, treatment and related expenses.
e. Low-cost and/or free screening tests for cancer.
f. Sidewalks, hiking/biking trails, fitness centers, physical fitness contests.
g. Farmers' markets, organic foods, healthier food choices in restaurants.
h. Employer wellness program to recognize employee healthy behavior practices.

Please rank your 1st, 2nd, and 3rd choices in the grid below:
a
b
c
d
e
f
g
h
1.
This idea is my 1st choice.
2.
This idea is my 2nd choice.
3.
This idea is my 3rd choice.

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