Cancer and Careers respects and protects the privacy of all visitors and users of our services. Cancer and Careers is the sole owner of any information collected through its programs. All information submitted will only be viewed by the Cancer and Careers staff and no identifying information will be shared publicly.

We strive to create programs and services that represent and serve the full diversity of the cancer community. We are asking the following demographic questions to ensure that we are meeting this goal.

Real-time closed captioning will be available at this event. If you require other reasonable accommodations to attend, kindly email us at cancerandcareers@cew.org with the subject line "Reasonable Accommodation Request."

*1.First Name(Required.)

*2.Last Name(Required.)

*3.Email Address(Required.)

*4.Phone Number(Required.)

*5.Mailing Address(Required.)

*6.City(Required.)

*7.State/Territory (if outside the United States, please select "Other" at the bottom of the dropdown menu and type in state/province and country)(Required.)

AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasU.S. Virgin IslandsUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOther (please specify)

*8.Zip Code(Required.)

9.Company/Organization (if applicable)

10.Title (if applicable)

*11.Age (or average age of patients you serve)(Required.)

Under 1818-2526-4041-5051-6061-70Over 70

*12.Which of the following categories, if any, apply to you?: (Please check all that apply.)(Required.)

Patient/Survivor

Healthcare professional (nurse, social worker, navigator, doctor, etc.)

Nonprofit professional

Caregiver

Friend/Family member

HR professional

Manager

Coworker

None of the above/Other (please specify)

*13.Treatment Status:(Required.)

Just diagnosed, pre-treatment

In-treatment (1 year or less)

In-treatment (1 year - 3 years)

In-treatment (3 years - 5 years)

In-treatment (5 years or more)

Post-treatment (5 years or less)

Post-treatment (5 years or more)

Not diagnosed

*14.Cancer Type (If you have never been diagnosed, please type "N/A.")(Required.)

*15.Which of the following best describes you?(Required.)

Woman

Man

Non-binary

Agender

Gender Fluid

I don't know / I am not sure

Prefer not to answer

Prefer to self-describe (please specify)

16.Are you transgender?

Yes

No

Prefer not to answer

17.What are your pronouns?

She/Her

He/Him

They/Them

Ze/Zir

Ze/Hir

Prefer not to answer

Prefer to self-describe

*18.Are you Hispanic, Latine, or Spanish descent?
(Required.)

Yes

No

I don't know

Prefer not to answer

*19.Which of the following best represents your race/ethnicity? Please select all that apply.(Required.)

Asian or Asian American

Black or African American

Hispanic, Latine, or Spanish origin

Middle Eastern or North African

Native American or Alaska Native

Native Hawaiian or other Pacific Islander

White Non-Hispanic

Don't know

Prefer not to answer

Prefer to self-describe

*20.Do you / the patients you serve speak any language besides English fluently?(Required.)

No

Yes, I speak one or more other language(s) fluently

Yes, the population I work with speaks one or more other language(s) fluently

21.If you answered Yes to the above:

I speak the following language(s) fluently

The population I work with speaks the following language(s) fluently

*22.Have you ever served in the U.S. military or the military reserves?(Required.)

Yes

No

Prefer not to answer

23.Please choose the option(s) that best reflect your ability status. We are interested in this identification regardless of whether you typically request accommodations. (Please select all that apply.)

I describe myself as a person:

With vision loss/low vision or who is blind

Who is hard of hearing or deaf

Who uses a wheelchair, crutch, or other assistive mobility device

With a brain injury or other acquired cognitive disability

A disability not listed above

I do not identify with a disability

Prefer not to answer

Prefer to self describe:

*24.Employment Status(Required.)

Employed full-time

Employed part-time

Self-employed

Employed full-time but looking for a new job

Employed part-time but looking for a new job

Unemployed, looking for full-time work

Unemployed, looking for part-time work

Neither employed nor looking for work

Retired