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Healthcare & Clinical

Oncology Patient Experience & Care Coordination Survey

Measures oncology patient perceptions of care access, appointment scheduling, provider coordination, and navigation support services. Designed for healthcare systems seeking to identify actionable gaps across the oncology care journey.

Sample questions

A preview of what’s in the template. Every question is editable before you launch.

26 questions · ~11 min
Q01
Message

Welcome to the Oncology Patient Experience Survey. This survey asks about your recent experiences with oncology care, including scheduling, care coordination, and support services. Your responses will help us identify areas for improvement. • Participation is voluntary and you may stop at any time. • There are no right or wrong answers — we want your honest opinions. • All responses are confidential and will be reported only in aggregate. • Estimated time: 7–10 minutes. By continuing, you indicate that you have read and understood this information and consent to participate.

Q02
Dropdown

When was your most recent oncology appointment?

  • Within the last 30 days
  • 31–90 days ago
  • 3–6 months ago
  • 6–12 months ago
  • More than 12 months ago
  • I have not had an oncology appointment
Q03
Opinion Scale

Overall, how easy has it been to access the oncology care you needed in the last 3 months?

Scale: 17
Min:Extremely difficultMax:Extremely easy
Q04
Opinion Scale

In the last 3 months, my care providers communicated well with each other about my treatment.

Scale: 17
Min:Strongly disagreeMax:Strongly agree
Q05
Multiple Choice

In the last 6 months, which navigation or support services did you use? Select all that apply.

  • Nurse navigator
  • Care coordinator
  • Social worker
  • Financial counselor
  • Transportation assistance
  • Language interpreter
  • Education classes or materials
  • Other (please specify)
  • I did not use any of these services
Q06
Long Text

Based on your experiences described in this survey, what could we improve to make navigating and coordinating your oncology care easier?

Q07
Dropdown

What is your age?

  • 18–24
  • 25–34
  • 35–44
  • 45–54
  • 55–64
  • 65–74
  • 75 or older
  • Prefer not to say
Q08
Message

Thank you for completing this survey. Your feedback is invaluable and will be used to improve oncology care access, scheduling, and coordination for patients like you.

Q09
Multiple Choice

In the last 6 months, which types of oncology care did you use? Select all that apply.

  • Medical oncologist
  • Radiation oncologist
  • Surgical oncologist
  • Infusion/chemotherapy center
  • Imaging/radiology
  • Survivorship/after-treatment clinic
  • Palliative care
  • Other (please specify)
  • None of the above
Q10
Multiple Choice

How did you schedule your most recent oncology appointment?

  • Phone call to clinic
  • Patient portal/online
  • In person at the clinic
  • Referral arranged by another office
  • Someone else scheduled for me
  • Other (please specify)
Q11
Opinion Scale

In the last 3 months, I felt well-informed about what to expect at each stage of my care.

Scale: 17
Min:Strongly disagreeMax:Strongly agree
Q12
Opinion Scale

Overall, how helpful were the navigation or support services you used?

Scale: 17
Min:Not at all helpfulMax:Extremely helpful
Q13
AI Interview

We'd like to learn more about your oncology care experience. An AI moderator will ask you a couple of follow-up questions based on your responses.

Q14
Multiple Choice

Which best describes your gender?

  • Woman
  • Man
  • Non-binary
  • Prefer to self-describe
  • Prefer not to say
Q15
Opinion Scale

For your most recent appointment, how easy was it to get a convenient date and time?

Scale: 17
Min:Very difficultMax:Very easy
Q16
Opinion Scale

In the last 3 months, transitions between different providers or departments went smoothly.

Scale: 17
Min:Strongly disagreeMax:Strongly agree
Q17
Opinion Scale

In the last 3 months, how clear was the information you received about your treatment options?

Scale: 17
Min:Very unclearMax:Very clear
Q18
Dropdown

What is your country of residence?

  • United States
  • Canada
  • United Kingdom
  • Australia
  • Germany
  • France
  • India
  • Other (please specify)
  • Prefer not to say
Q19
Dropdown

Approximately how long did you wait between scheduling and attending your most recent oncology appointment?

  • Same day
  • 1–3 days
  • 4–7 days
  • 8–14 days
  • 15–30 days
  • 31–60 days
  • More than 60 days
  • I don't remember
Q20
Multiple Choice

Is there one person who helps coordinate your oncology care across providers?

  • Yes
  • No
  • Not sure
Q21
Multiple Choice

In the last 3 months, which ways did your care team communicate with you between visits? Select all that apply.

  • Phone calls
  • Patient portal messages
  • Email
  • Text/SMS
  • Video visit/telehealth
  • Printed letters
  • Other (please specify)
  • No contact between visits
Q22
Dropdown

What is the highest level of education you have completed?

  • Less than high school
  • High school diploma or equivalent
  • Some college or 2-year degree
  • Bachelor's degree
  • Graduate or professional degree
  • Prefer not to say
Q23
Multiple Choice

In the last 3 months, which of the following made it difficult to arrange your oncology care? Select all that apply.

  • Finding available appointment times
  • Getting insurance approval or authorizations
  • Travel, transportation, or parking
  • Cost or co-pays
  • Work or caregiving conflicts
  • Not knowing whom to contact
  • Other (please specify)
  • I did not experience any barriers
Q24
Multiple Choice

After your most recent visit, did you receive a written or electronic care plan with next steps?

  • Yes
  • No
  • Not sure
Q25
Multiple Choice

What is your current employment status?

  • Employed full-time
  • Employed part-time
  • Self-employed
  • Unemployed and looking for work
  • Student
  • Retired
  • Homemaker/caregiver
  • Not currently working due to health or other reasons
  • Prefer not to say
Q26
Multiple Choice

Which racial or ethnic groups do you identify with? Select all that apply.

  • American Indian or Alaska Native
  • Asian
  • Black or African American
  • Hispanic or Latino/a/x
  • Middle Eastern or North African
  • Native Hawaiian or Pacific Islander
  • White
  • Another group
  • Prefer not to say

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • Purpose-built for oncology care journeys, covering access, scheduling wait times, provider coordination, and navigation/support service use rather than generic healthcare intake
  • Combines structured opinion-scale and multiple-choice questions with an open-text improvement question and a full AI follow-up interview to probe the 'why' behind low scores in real time
  • Captures care-coordination specifics competitors don't ask about, such as whether a single point-person coordinates care and whether patients received a written/electronic care plan after their visit
  • Every response is automatically quality-scored and compiled into a report, with transparent prompts showing exactly what the AI moderator asked and why

SurveySparrow

Free Patient Registration Form Template

This is a patient intake/registration form, not a patient-experience or care-coordination survey, so it addresses a different stage of the patient journey than our template. It's fielding-ready for collecting demographic and administrative intake data. Useful for onboarding, but it doesn't measure appointment access, provider coordination, or navigation support satisfaction.

What it does well

  • Likely quick to deploy for standard patient intake data collection
  • Mobile-friendly form format typical of SurveySparrow's template library

Where it falls short

  • Not designed to measure care experience, access, or coordination — different use case than an oncology experience survey
  • Static form fields with no adaptive follow-up probing on patient-reported gaps
  • No automated per-response quality scoring or AI-generated qualitative insight

Jotform

Patient Care Plan Template

This is a clinical care-plan documentation form for recording a patient's treatment plan, not a survey instrument for measuring patient-reported experience or coordination satisfaction. It's fielding-ready as a documentation tool but isn't structured to benchmark access, scheduling, or navigation support across a patient population. No oncology-specific content is present.

What it does well

  • Drag-and-drop form builder typical of Jotform, easy to customize fields
  • Can output structured care-plan records for clinical documentation

Where it falls short

  • Built for documenting a care plan, not surveying patients about their experience of coordination or access
  • No adaptive AI interviewing or voice AI to explore patient sentiment
  • No mechanism for automated quality scoring or synthesized reporting across many respondents

Ready to launch?

Open this template in the editor. Every part is yours to change before the first respondent sees it.

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