Newly Diagnosed/ Newly Connected Welcome Survey
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Welcome to the Cholangiocarcinoma Foundation.
We are so glad you found us. We appreciate the opportunity to support you or a loved one as you navigate the cholangiocarcinoma diagnosis journey. Please complete this short survey so we can understand how we may best help you. This survey will take approximately ten minutes to complete. This survey also serves as an order form for eligible households to receive a free Newly Diagnosed Care Kit.
Are you a cholangiocarcinoma patient or caregiver?
Patient
Caregiver
Please provide the patient's contact information:
First name
Last name
Address Line 1
Address Line 2
City
State/ Region/ Province
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
Zipcode
Email Address
Phone
Which of the following best represents the patient's ethnicity?
Hispanic or Latino
Not Hispanic or Latino
Which of the following best represents the patient's race?
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
White
Some other race
Prefer not to answer
Which of the following best represents the patient's gender?
Male
Female
Transgender Male
Transgender Female
Gender variant/non-conforming
Non-binary
Not listed
Prefer Not to Answer
What is the patient's marital status?
Single
Married
Partnered
Divorced
Separated
Widow/Widower
Prefer not to answer
Does the patient have any children?
Yes, all 18 or over
Yes, one or more under 18
No
Prefer not to say
What is the patient's highest level of education?
Less than high school
Completed some high school
High school graduate or equivalent (e.g., GED)
Completed some college or technical school, but no degree
Associates Degree or Technical school graduate
College graduate (e.g., BA, AB, BS)
Completed some graduate school, but no graduate degree
Completed graduate school (e.g., MS, MD, Ph.D., PharmD)
Prefer not to answer
What type of health insurance does the patient have?
No health insurance
Insurance coverage through a current or former employer or spouse’s/partner’s employer
Individual/Family insurance plan purchased directly by you
Insurance coverage through my parent’s or legal guardian’s employer
Medicaid (MediCal for California residents)
Medicare
Medicare Advantage
Veterans Administration (VA)/CHAMPUS/TRICARE
Preferred not to answer
What is the patient's total annual household income before taxes? (Please include money earned by the patient, spouse/partner, and any other adult in the household. Please give us your best estimate if you’re not sure.)
Less than $15,000
$25,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $124,999
$125,000 to $149,999
$150,000 to $199,999
$200,000 or over
Prefer not to answer
How did the patient hear about the Cholangiocarcinoma Foundation?
Search Engine (Google, Yahoo, Bing, etc)
Facebook
X (formerly Twitter)
LinkedIn
Instagram
Physican Referral
Friend / Family Member
Other
Other
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