Demystifying Palliative Care: Pre-Survey

On a scale of 0-5, where an answer closer to 0 means you are not confident at all and an answer closer to 5 means you are very confident... *

	0	1	2	3	4	5
How confident are you about your knowledge surrounding gynecologic cancers?	How confident are you about your knowledge surrounding gynecologic cancers? - 0	How confident are you about your knowledge surrounding gynecologic cancers? - 1	How confident are you about your knowledge surrounding gynecologic cancers? - 2	How confident are you about your knowledge surrounding gynecologic cancers? - 3	How confident are you about your knowledge surrounding gynecologic cancers? - 4	How confident are you about your knowledge surrounding gynecologic cancers? - 5

On a scale of 0-5 for each, where an answer closer to 0 means you do not agree at all and an answer closer to 5 means you strongly agree, how much do you agree with the following statements? *

	0	1	2	3	4	5
I am prepared to discuss gynecologic cancer and care with friends and loved ones.	I am prepared to discuss gynecologic cancer and care with friends and loved ones. - 0	I am prepared to discuss gynecologic cancer and care with friends and loved ones. - 1	I am prepared to discuss gynecologic cancer and care with friends and loved ones. - 2	I am prepared to discuss gynecologic cancer and care with friends and loved ones. - 3	I am prepared to discuss gynecologic cancer and care with friends and loved ones. - 4	I am prepared to discuss gynecologic cancer and care with friends and loved ones. - 5
I am prepared to discuss gynecologic cancers with a doctor.	I am prepared to discuss gynecologic cancers with a doctor. - 0	I am prepared to discuss gynecologic cancers with a doctor. - 1	I am prepared to discuss gynecologic cancers with a doctor. - 2	I am prepared to discuss gynecologic cancers with a doctor. - 3	I am prepared to discuss gynecologic cancers with a doctor. - 4	I am prepared to discuss gynecologic cancers with a doctor. - 5
I am comfortable discussing gynecologic cancer and care with friends and loved ones.	I am comfortable discussing gynecologic cancer and care with friends and loved ones. - 0	I am comfortable discussing gynecologic cancer and care with friends and loved ones. - 1	I am comfortable discussing gynecologic cancer and care with friends and loved ones. - 2	I am comfortable discussing gynecologic cancer and care with friends and loved ones. - 3	I am comfortable discussing gynecologic cancer and care with friends and loved ones. - 4	I am comfortable discussing gynecologic cancer and care with friends and loved ones. - 5
I am comfortable discussing gynecologic cancers with a doctor.	I am comfortable discussing gynecologic cancers with a doctor. - 0	I am comfortable discussing gynecologic cancers with a doctor. - 1	I am comfortable discussing gynecologic cancers with a doctor. - 2	I am comfortable discussing gynecologic cancers with a doctor. - 3	I am comfortable discussing gynecologic cancers with a doctor. - 4	I am comfortable discussing gynecologic cancers with a doctor. - 5

What would you like to gain the most through this series when it comes to gynecologic cancers and care? *

Ability to talk to friends and family

General knowledge

Ability to talk to medical professionals

Other (please specify)

What would you like to gain the most through this series when it comes to gynecologic cancers and care? Other (please specify)

What barriers in access to care do you and/or your loved one experience? *

What barriers in access to care do you and/or your loved one experience? Other (please specify)

We want to make sure we are talking to a lot of different kinds of people. How do you identify yourself? *

We want to make sure we are talking to a lot of different kinds of people. How do you identify yourself? Other...

Please indicate in what year you were born. *

Month

Day

Year

Please indicate in which state you currently live. *

Could you please indicate which race/ethnicity best describes you? *

Asian or Pacific Islander

Black/African American

Hispanic/Latinx (Puerto Rican, Mexican, etc.)

Native American or Indigenous

White

Prefer not to say

Other (please specify)

Could you please indicate which race/ethnicity best describes you? Other (please specify)

How would you describe your connection to today’s content? Choose as many as they currently apply *

Patient

Caregiver

Physician

Specialist

Other medical professional

Education professional in a related space

None of these/prefer not to say

Other (please specify)

How would you describe your connection to today’s content? Choose as many as they currently apply Other (please specify)

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Demystifying Palliative Care: Pre-Survey