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2014 COCACares Survey

Page One

COCACARES FINANCIAL ASSISTANCE: The Colorado Ovarian Cancer Alliance (COCA) is dedicated to supporting women who have been diagnosed with ovarian cancer. The COCACares program provides financial assistance for qualified applicants. Please take a few minutes to share your thoughts about the COCACares program.
1. In the last 12 months, have you applied for financial assistance through the COCACares program?
2. In the last 12 months, have you helped someone apply for financial assistance through the COCACares program?
3. In the last 12 months, have you received financial assistance through the COCACares program?
5. If you have applied for assistance, please check the boxes that best reflect your experience with the application process of COCACares.
Space Cell 5 (very easy)4 (easy) 3 (okay)2 (difficult)1 (very hard)
Finding out about the program
Understanding the program limits
Filling out the application
Getting the Medical Verification form filled out by doctor/nurse
Tracking the application status
Overall application process
Other (please describe below)
6. Were you placed on a waitlist for assistance?
7. If you have received assistance, please check the boxes that best reflect your experience with the payment process of COCACares.
Space Cell 5 (very easy)4 (easy)3 (okay)2 (difficult)1 (very hard)
Getting assistance started quickly
Deciding on which bills to be paid
Submitting expenses/bills
Receiving notification of bills paid
Contacting the COCACares coordinator
Overall payment process
Other (please describe below)
8. Please check the box that best describes the impact of COCACares.
Space Cell I would have been unable to pay for this expense without COCACaresI would have paid this bill somehow, but COCACares significantly reduced my stress with its assistanceI did not use COCACares for this
Rent/mortgage
Medical insurance premiums and/or medical bills
Groceries
Transportation/car-related expenses
Utilities
Gynecologic oncologist visit
Transportation to a clinical trial
Other (please describe below)
10. Where do you live?
11. How old are you?
12. Do you have a family history of cancer? (Check all that apply)
13. What is your ethnic background? (optional)
15. May we use the comments in #14 in COCA marketing materials?
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