Survey for Cancer Answer Directory

Submit Survey by Online Form or Printing PDF

You are able to submit the survey by the online form below or by clicking on the Download PDF Survey button to print and submit the survey.
  • What is the name of your organization?
  • 1. Which county does your organization provide information and resources to?*

  • YesNo
  • YesNo
  • YesNo
  • YesNo
  • YesNo
  • YesNo
  • YesNo


  • 2. Please select the service type(s) that your organization offers to the patients.*


  • Does your organization provide Transportation Services?
    YesNo
  • If selected yes, please select the following for your Transportation Services.
    FreeLow cost based on incomePayment plans availableWe accept health insurance (call to see which plans)
  • If selected yes, please provide a description of your Transportation Services.


  • Does your organization provide Financial/ Insurance/ Legal Services?
    YesNo
  • If selected yes, please select the following for your Financial / Insurance / Legal services.
    FreeLow cost based on incomePayment plans availableWe accept health insurance (call to see which plans)
  • If selected yes, please provide a description of your Financial / Insurance / Legal services.


  • Does your organization provide Support Services (crisis centers, spiritual, groups, counseling, caregiver, etc.)?
    YesNo
  • If selected yes, please select the following for your Support Services.
    FreeLow cost based on incomePayment plans availableWe accept health insurance (call to see which plans)
  • If selected yes, please provide a description of your Support Services.


  • Does your organization provide Access to Care (education & screening, free clinics, translation services, navigators, social workers, etc.)?
    YesNo
  • If selected yes, please select the following for your Access To Care services.
    FreeLow cost based on incomePayment plans availableWe accept health insurance (call to see which plans)
  • If selected yes, please provide a description of your Access To Care services.


  • Does your organization provide Healthcare (hospitals, clinics, medical supplies, wigs, colostomy, pain & symptom management, etc.)?
    YesNo
  • If selected yes, please select the following for your Healthcare services.
    FreeLow cost based on incomePayment plans availableWe accept health insurance (call to see which plans)
  • If selected yes, please provide a description of your Healthcare services.


  • Does your organization provide Basic Living Needs (food, housing, utilities, gas, etc.)?
    YesNo
  • If selected yes, please select the following for your Basic Living Needs services.
    FreeLow cost based on incomePayment plans availableWe accept health insurance (call to see which plans)
  • If selected yes, please provide a description of your Basic Living Needs services.


  • Does your organization provide Family/ Caregiver (eldercare, pet, child, nursing homes, assisted living, etc.) services?
    YesNo
  • If selected yes, please select the following for your Family / Caregiver services.
    FreeLow cost based on incomePayment plans availableWe accept health insurance (call to see which plans)
  • If selected yes, please provide a description of your Family / Caregiver services.


  • Does your organization provide Wellness/ Healthy Lifestyle (dietitians, exercise, screenings, volunteers, survivor programs, etc.) services?
    YesNo
  • If selected yes, please select the following for your Wellness / Healthy Lifestyle services.
    FreeLow cost based on incomePayment plans availableWe accept health insurance (call to see which plans)
  • If selected yes, please provide a description of your Wellness / Healthy Lifestyle services.


  • 3. Please provide Organization Details

    Please list the following: