Request edit access
Structures of Support - Healthcare
Structures of Support is an ongoing, multi-phase project by The Think Tank that has yet to be named (Jeremy Beaudry, Katie Hargrave, and Meredith Warner). Our goal is to develop a clearer understanding of how our support structures are created and maintained, and how we might then work to build more resilient and robust support structures in the future.

This survey focuses on one of our most important supports: healthcare for an upcoming exhibition at Weinberg/Newton Gallery (http://weinbergnewtongallery.com/) in Chicago. The gallery has partnered with the Metropolitan Chicago Breast Cancer Task Force (http://www.chicagobreastcancer.org/), which works to reduce the racial, ethnic and class disparity in breast cancer death rates, and the show’s aim is to shed light on systemic barriers to quality healthcare through the lens of breast cancer.

Your responses are voluntary and will be confidential. Responses will not be identified by individual, and all responses will be compiled together and analysed as a group. It should take approximately 10 minutes to complete. To have a better of how the data we collect will be shared, you can view sample images of the past work of this project here: http://www.wearethethinktank.org/2013/03/structures-of-support/

What is the zipcode of your primary residence?
Your answer
What do you worry about?
Your answer
What do you do to support yourself that contributes to your quality of life?
(emotionally, spiritually, physically, and creatively)
Your answer
What support are you lacking?
(emotionally, spiritually, physically, and creatively)
Your answer
How many people do you feel personally responsible to take care of?
Your answer
Who cares for you and how?
Your answer
How many miles away from your primary residence is your closest loved one (that you don't live with)?
Your answer
How many miles away from your primary residence is the healthcare provider you see most often?
Your answer
What are 5 words you associate with healthcare?
Your answer
What are 5 words you associate with your health?
Your answer
Overall, are you satisfied or dissatisfied with your healthcare?
Please explain
Your answer
What are three words you would use to describe your quality of life?
Your answer
Optional: Request for follow up interview
Would you be willing to discuss your survey responses further?
If you are comfortable with revealing your identity, please enter your name and email address so that a member of the Think Tank may contact you.
Your answer
Thank you!
We appreciate your willingness to participate in our project!
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service