|
Work/Life Connections Questionnaire |
|
Project Overview Good Health for Life is dedicated to efforts that oppose the marginalization of cancer survivors from the workplace. We deem it unacceptable that businesses should squander the talents of the current 9 million American cancer survivors and those that will be diagnosed in the coming years. In addition we ask, why should they be forced to burden the Social Security and Medicare system when they can continue to contribute to society? As part of its efforts, the non-profit engages in advocacy to encourage the business community to see merit in working with cancer survivors. In order to lend factual and emotional credibility to this effort, we will be conducting survey research together with a series of on-camera interviews with cancer survivors. The survey will focus on the effect of work on a cancer survivor’s life, while the interviews will provide personal accounts of the workplace experiences of a diverse group of survivors. Invitation to ParticipateUnfortunately there is a lack of information concerning the way work affects cancer survivors and the corollary effects of this work on the larger community that supports them. As a cancer survivor, we invite you to assist us in understanding your experiences. To do this, we ask that you complete the following questionnaire (see link below). It is expected that it will take approximately 20-30 minutes to complete the questionnaire. Your PrivacyIt is important to understand that this information will be used to help others cope with their diagnosis and treatment of cancer and understand the value that work can play in their recovery. Just as important, it will help us to educate the business community and government organizations on the value of working with these exceptional people. We need you to be aware that we are not asking you to provide any information that will allow us to identify you, unless you decide to supply it yourself. In addition, the researchers to obtain further information will not contact you unless you request it. Please review our online privacy statement. If you have any questions, please don’t hesitate to contact us. Return completed questionnaire to the person who gave it to you, or please fax or email it to Good Health for Life.Please print a copy of this questionnaire and return it completed to Good Health for Life.
In advance we thank you for your participation!
|
Research QuestionnaireBackground InformationThe following information will help us to determine the extent to which our respondents represent the population of cancer survivors. It cannot be used to trace individuals. 1. Are you? ◘ Female ◘ Male 2. When were you born? Month: _____ Day:_____ Year:_______ 3. Are you? (check all that apply) ◘ Cancer Survivor ◘ Employer ◘ Co-worker of a cancer survivor ◘ Family member of a cancer survivor ◘ Employee ◘ Entrepreneur 4. What was your age at the time of diagnosis? Years:_______ 5. What was your diagnosis? _______________________________________________________ 6. From diagnosis through treatment, how long was your treatment? Months: _________ 7. What treatments did you receive? ◘ Chemotherapy ◘ Radiation ◘ Surgery ◘ Alternative therapy 8. What is the approximate population of the community in which you live? ◘ < 5,000 ◘ 5,000 – 49,999 ◘ 50,000 – 249,999 ◘ 250,000 – 999,999 ◘ >1 million 9. What is your zip code? ________________ 10. How many miles from the treatment center did you live while being treated? ______ 11. How did you get to treatment? ◘ Own car ◘ Relied on family ◘ Public transportation ◘ Cancer society volunteer ◘ Other 12. What language do you speak most often at home? ◘ English ◘ Italian ◘ Spanish ◘ Chinese ◘ Vietnamese ◘ French ◘ German ◘ Other 13. What is your marital status? ◘ Never married ◘ Widowed ◘ Divorced ◘ Married/living with intimate partner 14. Do you now live (check all that apply): ◘ As a single parent ◘ With partner/spouse ◘ With children – if so, how many? ________ Ages? ____________ ◘ With other family ◘ Alone ◘ Other 15. What was your main activity when you were diagnosed? (check all that apply) ◘ Working at a job ◘ Working outside the home ◘ Working from home/telecommuting ◘ Homemaker ◘ Looking for work ◘ Going to school ◘ Unable to work due to illness 16. What is your usual occupation? ______________________________ 17. What is your partner’s/spouse’s usual occupation? ______________________ 18. How long after your diagnosis did you notify your employer? ◘ Within 1 week ◘ Within 1 month ◘ Never felt able to reveal my cancer diagnosis to anyone in the workplace 19. How has your paid life work changed as a result of your illness? [check all that apply] ◘ My work life has not changed ◘ I have stopped working entirely ◘ I have reduced the number of hours of work ◘ I have changed the nature of my work ◘ I was not working when I was diagnosed, but now I want to work ◘ Work is now more important to me ◘ I wish I could stop working ◘ I was not working when I was diagnosed, but now I must work 20. How has your partner’s/spouse’s work life work changed as a result of your illness? [check all that apply] ◘ Their work life has not changed ◘They have stopped working entirely ◘ They have reduced their number of work hours ◘ They have changed the nature of their work ◘ They were not working when I was diagnosed, but now they want to ◘ Work is now more important to them ◘ They wish they could stop working ◘ They were not working when I was diagnosed, but now they must work 21. What is the highest level of education you have completed? ◘ No formal schooling ◘ Some high school ◘ Completed high school ◘ Some college ◘ University degree ◘ Postgraduate 22. In which of the following ranges does your total annual household income lie? ◘ < $10,000 ◘ $10,000 - $24,999 ◘ $25,000 - $49,999 ◘ $50,000 - $99,999 ◘ >$100,000 23. Would you describe yourself as an entrepreneur? ◘ No ◘ Yes 24. Do you have an idea for a business that you would like to start, but feel you need help to succeed? ◘ No ◘ Yes 25. Have you experienced emotional difficulties with any of the following individuals? [check all that apply]
26. Have you experienced a decrease in energy that is difficult to deal with? ◘ Never ◘ Only once ◘ A few times ◘ Frequently ◘ Always 27. Are you now managing long-term effects? ◘ Yes ◘ No If yes, please briefly describe them. ________________________________________ 28. How much time passed from the time you first noticed a change until you first sought medical help? ◘ I never noticed a change ◘ Less than one month ◘ 1 – 3 months r 4 – 6 months ◘ 7 – 12 months ◘ 1 – 5 years ◘ 5 or more years 29. How much time passed from when you first sought help until you received a definitive diagnosis? ◘ Less than one month ◘ 1 – 3 months ◘ 4 – 6 months r 7 – 12 months ◘ 1 – 2 years ◘ 3 or more years 30. From whom did you first seek medical help? ◘ Family physician ◘ Emergency room ◘ Walk-in clinic ◘ Pediatrician ◘ Specialist ◘ Other _____________________________ 31. Did you get a second opinion before starting treatment? ◘ Yes ◘ No 32. Are you receiving treatment for cancer now? ◘ Yes ◘ No 33. If yes, which? [check all that apply] ◘ Radiation therapy ◘ Chemotherapy ◘ Alternative therapy ◘ Surgery ◘ Other 34. In the last year, how much have you paid for medical treatment for your cancer? ◘ $0 ◘ $1 - $999 ◘ $1,000 - $4,999 ◘ $5,000 - $9,999 ◘ $10,000 - $49,999 ◘ More than $50,000 35. My company’s insurance program covered my treatment? [check all that apply] ◘ Yes, completely ◘ No, but my employer worked with me to get me covered ◘ No, I have had to make up the difference ◘ I have no private insurance ◘ Medicare and/or other supplemental health insurance programs cover me ◘ Payment of my medical expenses has been covered in part or whole by a non-profit organization ◘ Other _____________________________ 36. Please rate the impact of your illness on the following. For each item, circle a number from 1 to 7, where 7 indicates a positive impact, 1 indicates a negative impact, and 4 is neutral, and 7 is positive. Employment opportunities 1 2 3 4 5 6 7 Relationship with spouse 1 2 3 4 5 6 7 Relationship with children 1 2 3 4 5 6 7 Relationship with boss 1 2 3 4 5 6 7 Relationship with co-workers 1 2 3 4 5 6 7 Work life (inside/outside home) 1 2 3 4 5 6 7 Financial status 1 2 3 4 5 6 7 Leisure time 1 2 3 4 5 6 7 Psychological well-being 1 2 3 4 5 6 7 37. Have you changed your spiritual lifestyle since your cancer diagnosis? ◘ Yes ◘ No 38. Please describe the impact of your diagnosis and treatments on the quality of your life. _______________________________________________________________________________________ _______________________________________________________________________________________ 39. What impact did your diagnosis and treatment have on your family, if any? _______________________________________________________________________________________ _______________________________________________________________________________________ 40. What impact did your diagnosis and treatment have on your job, if any? _______________________________________________________________________________________ _______________________________________________________________________________________ 41. Please describe the role of work in your life since you were diagnosed and treated. _______________________________________________________________________________________ _______________________________________________________________________________________ 42. Please indicate the benefits you gain from work. [check all that apply] ◘ None ◘ Insurance coverage ◘ Opportunity to help others ◘ Chance to make a difference ◘ Encouragement & reinforcement ◘ Coping with stigma and isolation ◘ Coping with the financial burden ◘ Coping with lifestyle change ◘ Other 43. Are there also drawbacks? Please explain. _______________________________________________________________________________________ _______________________________________________________________________________________ 44. Do you believe you were fired or laid off as a result of your illness? ◘ No ◘ Yes
Click here to complete the questionnaire 1 | 2 …
|
|
530.622.9118 530.622.9119—Fax info@ghfl.org |
|
© 2004 Good Health for Life, Inc. All rights reserved. |
|
|
Often |
Once in a While |
Only Once |
Never |
|
Spouse |
|
|
|
|
|
Siblings |
|
|
|
|
|
Parents |
|
|
|
|
|
Boss |
|
|
|
|
|
Co-Workers |
|
|
|
|
|
Children |
|
|
|
|
|
Grandparents |
|
|
|
|
|
Friends |
|