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2017 COCACares Survey for recipients

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?

4. What suggestions do you have regarding ways to find out about 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	Finding out about the program: 5 (very easy)	Finding out about the program: 4 (easy)	Finding out about the program: 3 (okay)	Finding out about the program: 2 (difficult)	Finding out about the program: 1 (very hard)
Understanding the program limits	Understanding the program limits: 5 (very easy)	Understanding the program limits: 4 (easy)	Understanding the program limits: 3 (okay)	Understanding the program limits: 2 (difficult)	Understanding the program limits: 1 (very hard)
Filling out the application	Filling out the application: 5 (very easy)	Filling out the application: 4 (easy)	Filling out the application: 3 (okay)	Filling out the application: 2 (difficult)	Filling out the application: 1 (very hard)
Getting the Medical Verification form filled out by doctor/nurse	Getting the Medical Verification form filled out by doctor/nurse: 5 (very easy)	Getting the Medical Verification form filled out by doctor/nurse: 4 (easy)	Getting the Medical Verification form filled out by doctor/nurse: 3 (okay)	Getting the Medical Verification form filled out by doctor/nurse: 2 (difficult)	Getting the Medical Verification form filled out by doctor/nurse: 1 (very hard)
Tracking the application status	Tracking the application status: 5 (very easy)	Tracking the application status: 4 (easy)	Tracking the application status: 3 (okay)	Tracking the application status: 2 (difficult)	Tracking the application status: 1 (very hard)
Overall application process	Overall application process: 5 (very easy)	Overall application process: 4 (easy)	Overall application process: 3 (okay)	Overall application process: 2 (difficult)	Overall application process: 1 (very hard)
Other (please describe below)	Other (please describe below): 5 (very easy)	Other (please describe below): 4 (easy)	Other (please describe below): 3 (okay)	Other (please describe below): 2 (difficult)	Other (please describe below): 1 (very hard)

Comments

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	Getting assistance started quickly: 5 (very easy)	Getting assistance started quickly: 4 (easy)	Getting assistance started quickly: 3 (okay)	Getting assistance started quickly: 2 (difficult)	Getting assistance started quickly: 1 (very hard)
Deciding on which bills to be paid	Deciding on which bills to be paid: 5 (very easy)	Deciding on which bills to be paid: 4 (easy)	Deciding on which bills to be paid: 3 (okay)	Deciding on which bills to be paid: 2 (difficult)	Deciding on which bills to be paid: 1 (very hard)
Submitting expenses/bills	Submitting expenses/bills: 5 (very easy)	Submitting expenses/bills: 4 (easy)	Submitting expenses/bills: 3 (okay)	Submitting expenses/bills: 2 (difficult)	Submitting expenses/bills: 1 (very hard)
Receiving notification of bills paid	Receiving notification of bills paid: 5 (very easy)	Receiving notification of bills paid: 4 (easy)	Receiving notification of bills paid: 3 (okay)	Receiving notification of bills paid: 2 (difficult)	Receiving notification of bills paid: 1 (very hard)
Contacting the COCACares coordinator	Contacting the COCACares coordinator: 5 (very easy)	Contacting the COCACares coordinator: 4 (easy)	Contacting the COCACares coordinator: 3 (okay)	Contacting the COCACares coordinator: 2 (difficult)	Contacting the COCACares coordinator: 1 (very hard)
Overall payment process	Overall payment process: 5 (very easy)	Overall payment process: 4 (easy)	Overall payment process: 3 (okay)	Overall payment process: 2 (difficult)	Overall payment process: 1 (very hard)
Other (please describe below)	Other (please describe below): 5 (very easy)	Other (please describe below): 4 (easy)	Other (please describe below): 3 (okay)	Other (please describe below): 2 (difficult)	Other (please describe below): 1 (very hard)

Comments

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 COCACares	I would have paid this bill somehow, but COCACares significantly reduced my stress with its assistance	I did not use COCACares for this
Rent/mortgage	Rent/mortgage: I would have been unable to pay for this expense without COCACares	Rent/mortgage: I would have paid this bill somehow, but COCACares significantly reduced my stress with its assistance	Rent/mortgage: I did not use COCACares for this
Medical insurance premiums and/or medical bills	Medical insurance premiums and/or medical bills: I would have been unable to pay for this expense without COCACares	Medical insurance premiums and/or medical bills: I would have paid this bill somehow, but COCACares significantly reduced my stress with its assistance	Medical insurance premiums and/or medical bills: I did not use COCACares for this
Groceries	Groceries: I would have been unable to pay for this expense without COCACares	Groceries: I would have paid this bill somehow, but COCACares significantly reduced my stress with its assistance	Groceries: I did not use COCACares for this
Transportation/car-related expenses	Transportation/car-related expenses: I would have been unable to pay for this expense without COCACares	Transportation/car-related expenses: I would have paid this bill somehow, but COCACares significantly reduced my stress with its assistance	Transportation/car-related expenses: I did not use COCACares for this
Utilities	Utilities: I would have been unable to pay for this expense without COCACares	Utilities: I would have paid this bill somehow, but COCACares significantly reduced my stress with its assistance	Utilities: I did not use COCACares for this
Gynecologic oncologist visit	Gynecologic oncologist visit: I would have been unable to pay for this expense without COCACares	Gynecologic oncologist visit: I would have paid this bill somehow, but COCACares significantly reduced my stress with its assistance	Gynecologic oncologist visit: I did not use COCACares for this
Transportation to a clinical trial	Transportation to a clinical trial: I would have been unable to pay for this expense without COCACares	Transportation to a clinical trial: I would have paid this bill somehow, but COCACares significantly reduced my stress with its assistance	Transportation to a clinical trial: I did not use COCACares for this
Other (please describe below)	Other (please describe below): I would have been unable to pay for this expense without COCACares	Other (please describe below): I would have paid this bill somehow, but COCACares significantly reduced my stress with its assistance	Other (please describe below): I did not use COCACares for this

Comments

9. What suggestions do you have to make COCACares more supportive and/or easy to use?

10. Where do you live?

Comments

11. How old are you?

12. Do you have a family history of cancer? (Check all that apply)

Comments

13. What is your ethnic background? (optional)

Comments

14. Please share the difference/impact that COCACares has made on you and/or your family.

15. May we use the comments in #14 in COCA marketing materials?

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