GC3 Survivorship Advocacy Council Questionnaire

Cancer Survivor and Caregiver Voices Needed!

As we embark on implementing the survivorship objectives and strategies of the new 5 year plan, we want to establish a GC3 Survivorship Advocacy Council to bring a diverse group of survivor and caregiver voices to ensure our work is relevant to communities and populations across the state.

We will develop educational materials about cancer survivorship that will be disseminated to healthcare professionals and organizations across the state. We will develop materials that can be shared will legislators to educate them about the resources and support needed for survivors.

There are various roles for the Survivorship Advocacy Council members. Here are a few:

- Review and provide feedback on the educational materials
- Assist with the dissemination of the materials
- Participate in educational sessions about cancer survivorship
- Contact legislators to share your story and the importance of supporting survivorship efforts in our state

If you are interested in being a member of the GC3 Survivorship Advocacy Council, please take a few minutes to tell us a little bit about yourself by completing the survey.

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* 1. Contact Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. What counties do you live in and work in?

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* 3. What is the best way to contact you?

Phone

Text

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* 4. What best describes your role?

Survivor

Caregiver

Both survivor and caregiver

Other (please specify)

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* 5. Please check all cancer type(s) you have been diagnosed with:

Bladder

Blood (leukemia, lymphoma, multiple myeloma)

Brain

Breast

Cervical

Colon or rectal

Endometrial

Head and Neck

Kidney

Liver

Lung

Melonoma

Ovarian

Pancreatic

Prostate

Skin (non-melanoma)

Thyroid

Other (please specify)

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* 6. How long has it been since your last cancer treatment?

Less than one year

1 - 5 years

5 - 10 years

More than 10 years

Still undergoing treatment for Metastatic disease

Not a survivor

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* 7. I would be available to participate in the following ways: (choose all options that apply)

1 hour phone call each quarter

Review materials and provide feedback through email

Participate in an educational program by sharing my story

Contact legislators to tell my story and share materials

Assist with dissemination of materials

Host an educational webinar

Other (please specify)

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* 1. Contact Information

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* 2. What counties do you live in and work in?

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* 3. What is the best way to contact you?

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* 4. What best describes your role?

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* 5. Please check all cancer type(s) you have been diagnosed with:

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* 6. How long has it been since your last cancer treatment?

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* 7. I would be available to participate in the following ways: (choose all options that apply)

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* 8. Please share any additional information or questions.