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MARKET RESEARCH SURVEY
Dear Participant:
BarbaraCares always advocates to save lives. Your participation in this survey will better allow our organization to tailor programs and outreaches within the local community to address late-stage breast cancer diagnoses and help reduce mortality rates. Please answer with truthfulness to the best of your ability. This market research survey questionnaire will help us greatly improve our approach. Rest assured that the information you on this survey questionnaire will be made confidential.
*
Indicates required field
1) How frequently do you visit the doctor or make an appointment?
*
Daily
Weekly
Monthly
Yearly
On Special Occasions only
Rarely
Once or Twice
Never
2) When was your last mammogram / years since last screening?
*
1 Year
2 Years
3 - 5 Years
6+ Years
Never
3) What is your age group?
*
18 - 25
26 - 35
36 - 40
41 - 49
50 - 64
65+
4) What is your race / ethnicity?
*
Asian
African American
Causcasian
Latino / Hispanic
Other
5) Do you currently have health insurance?
*
Yes
No
6) Have you had breast cancer?
*
Yes
No
7) Has anyone in your immediate family had breast cancer?
*
Yes
No
8) Do you know someone affected by breast cancer?
*
Yes
No
9) Do you know how to do a self-breast exam?
*
Yes
No
10) What are some barriers for women who do not get a mammogram? Select all that apply.
*
Beliefs
Fears
Transportation
Cost
Can't get away / Off from work
Lack of childcare for the appointment
It’s uncomfortable
Other
11) How do you prefer to hear medical information?
*
Your doctor
Other medical professionals
Community presentations / health fairs
Someone who has personal knowledge / experience
Local health departments
Media (radio, tv, movies)
Social Media (Facebook, Twitter, Instagram, Internet Ads, etc.)
Your own research
12) Have you heard about the BarbaraCares Mammogram’s Matter Program that provides coverage for uninsured, underinsured, and at-risk women to receive a mammogram?
*
Yes
No
13) Gender Identity. Do you identify as:
*
Male
Female
Other
14) Are you aware of any health fairs or community resources in your area?
*
Yes
No
15) Would you like to see more health fairs offered at community centers in this area?
*
Yes
No
Indifferent
16) What zip code do you live in?
*
17) How many people are in your home?
*
1 - 2
3 - 5
6+
No other people beside myself
18) How many children, below 18 are in your home?
*
1 - 2
3 - 5
6+
None
Name
*
First
Last
Email
*
Phone Number
*
19) Do you agree to be contacted via phone, email or mailing list for a follow-up?
*
Yes
No
Submit
BarbaraCares
About
Barbara's Story
Diversity & Inclusivity Statement
Sign Up
Financials
Online Application
Community Impact
Community Impact 2019
Community Impact 2020
Community Impact 2021
Community Impact 2022
Community Impact 2023
Community Impact 2024
Community Impact 2025
Community Impact 2026
The Board
Advice from the Vice
Employee Portal
Intern Portal
Board Portal
Board Application
Online Giving
Sponsorship
Donate A Mammogram
Online Giving
Events
Mobile Mammogram Health
March For Mammograms
Contact
Volunteer
Sign Up
News Room
Health Portal
Mobile Mammogram Health
