First Name
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Last Name
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Date of birth
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Today M-D-Y
City where you live/reside
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State where you live/reside.
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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
Patient
Caregiver
High risk
No personal experience
Are you more than 1 year post your most recent cancer diagnosis and done with initial treatment
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Yes
No
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
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
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
No
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
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?
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What type of treatment did they receive?
Bone marrow therapy (BMT)
Chemotherapy
Hormone therapy
Immunotherapy
Radiation
Surgery
Other
Bone marrow therapy (BMT)
Chemotherapy
Hormone therapy
Immunotherapy
Radiation
Surgery
Other
Why are you considered 'high risk' for cancer?
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strong family history
positive genetic test
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
No
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
No
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
No
Please tell us more.
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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
No
Are you willing and able to commit approximately 20 hours per year (after initial training) to the ARM Program, depending on need?
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Yes
No
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
No
Submit
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