LLS Survey Form

LLS Survey Template

Name *

First

Last

Email *

Zip Code *

Constituent Type (select all that apply) *

Caregiver
Patient/Survivor
Family Member
Friend
Generally Interested Individual
LLS Staff
HCP

Family Member Type *

HCP Type *

Your / Patient's Diagnosis (select all that apply) *

Acute lymphoblastic leukemia (ALL)
Acute myeloid leukemia (AML)
Chronic myeloid leukemia (CML)
Chronic lymphocytic leukemia/Small cell lymphoma (CLL/SLL)
Hodgkin lymphoma (HL)
Myeloma
Myelodysplastic syndromes (MDS)
Myeloproliferative neoplasms (MPN)
Non-Hodgkin lymphoma (NHL)
Other Blood Cancer
Other Non-Blood Cancer
Other Diagnosis

Other Blood Cancer *

Other Non-Blood Cancer *

Other Diagnosis *

What year was the patient/survivor born? *

What year was the patient diagnosed? *

Has the patient/survivor ever served on active duty in the U.S. Armed Forces, military Reserves, or National Guard? *

With which race(s)does the patient/survivor identify? (select all that apply) *

American Indian or Native Alaskan
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Some other race
Prefer not to answer

Does the patient/survivor identify as Hispanic, Latino or Spanish origin? *

Please describe any information you expected to get from this program but did not receive

Please give us any additional feedback about this program

Support for this program is provided by Bristol Myers Squibb; Genentech, Inc. & Biogen; Merck & Co., Inc.; Pharmacyclics, An AbbVie Company & Janssen Biotech.

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