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d6gJchLw3VECgMLrtQyq9RdpYGdoRqyUasUZCIGuBb

Interest Form : Advocates for Research in Medicine (ARM) Program

Thank you for your interest in becoming a patient/caregiver ARM Advocate! Please complete the questions below.

First Name

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Last Name

* must provide value

Date of birth

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M-D-Y

City where you live/reside

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State where you live/reside.

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Primary phone

E-mail address

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Gender

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male

female

non-binary

Personal experience with cancer: please select one:

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Patient

Caregiver

High risk

No personal experience

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Are you more than 1 year post your most recent cancer diagnosis and done with initial treatment

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Yes

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What type (s) of cancer did you have? Select all that apply.

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Brain

Breast

Endocrine (thyroid, adrenal, pituitary)

Gastrointestinal (colon/rectal, esophageal, liver, stomach, pancreatic, gallbladder)

Genitourinary (bladder, prostate, kidney, testicular)

Gynecologic (endometrial, ovarian, uterine, cervical, vaginal)

Head and Neck (oral cavity, pharynx, salivary glands, tongue)

Hematologic (lymphoma, leukemia, multiple myeloma)

Melanoma (skin cancer)

Sarcoma

Thoracic (lung)

Other

Please specify

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What type(s) of treatment did you receive? Select all that apply.

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Bone marrow transplant (BMT)

Chemotherapy

Hormone therapy

Immunotherapy

Radiation

Surgery

Other

Please specify

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Is the person/loved one you cared for more than 1 year past their most recent cancer diagnosis?

* must provide value

Yes

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What type of cancer did the person/loved one you cared for have?

* must provide value

Brain

Breast

Endocrine (thyroid, adrenal, pituitary)

Gastrointestinal (colon/rectal, esophageal, liver, stomach, pancreatic, gallbladder)

Genitourinary (bladder, prostate, kidney, testicular)

Gynecologic (endometrial, ovarian, uterine, cervical, vaginal)

Head and Neck (oral cavity, pharynx, salivary glands, tongue)

Hematologic (lymphoma, leukemia, multiple myeloma)

Melanoma (skin cancer)

Sarcoma

Thoracic (lung)

Other

What "other" type of cancer did they have?

* must provide value

What type of treatment did they receive?

Bone marrow therapy (BMT)

Chemotherapy

Hormone therapy

Immunotherapy

Radiation

Surgery

Other

Why are you considered 'high risk' for cancer?

* must provide value

strong family history

positive genetic test

Please tell us why you are passionate about becoming a research patient advocate in the ARM program at Atrium Health Wake Forest Baptist Comprehensive Cancer Center:

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Do you have previous research experience or exposure? (Either participating in or assisting with a clinical research study in a professional capacity?)

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Yes

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Please tell us more.

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Do you have previous formal research advocate experience (e.g. grant reviewer, study team member)?

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Yes

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Please tell us more.

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Do you have any formal patient advocate experience (e.g. running a support group, patient advisory council, serving as a mentor to other patients)?

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Yes

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Please tell us more.

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Expand

Are you willing and able to attend a web-based one-time training session that will consist of 2 half-days?

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Yes

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Are you willing and able to commit approximately 20 hours per year (after initial training) to the ARM Program, depending on need?

* must provide value

Yes

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Are you willing and able to comply with Wake Forest Baptist Health's background check and immunization policy for volunteers?

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Yes

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.