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SurvivingBreastCancer.org (QOL-BC)
The purpose of this questionnaire is to help us understand how those diagnosed with breast cancer are experiencing life after a diagnosis so that we can better serve and meet your needs.
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Demographics
What is your age?
Under 18 years
18-24 years
25-34 years
35-44 years
45-54 years
55-64 years
65-74 years
Over 75 years
Clear selection
What is your current gender identify?
Female
Male
Transgender [male]
Transgender [female]
Prefer not to say
Other:
Clear selection
What is your ethinicity?
Asian
Black/ African American
Hispanic/ Latino
Native American/ American Indian
White/ Caucasian
Other:
Clear selection
What is the highest level of education you have completed?
Less than high school
Equivalent to high school
Associates degree
Bachelor's degree
Master's degree
Doctoral degree
Other
Clear selection
What is your current employment status?
Full-Time
Part-Time
Unemployed
Student, not working
Student and working
Retired
Self-employed
Clear selection
What is your marital status?
Single
Married
In a domestic relationship
Divorced
Widowed
Other:
Clear selection
What is your household income?
Below 10K
10K-26.5K
26.6K-50K
51K-100K
101K-150K
151K-200K
Above 200K
Clear selection
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