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* 1. Name

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* 2. Pronouns (ie: they/she/he/xe)

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* 3. Company

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* 4. Address

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* 5. City

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* 6. State

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* 7. Zip Code

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* 8. Country

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* 9. Email Address

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* 10. Phone Number

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* 11. Birth Year

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* 12. How do you identify in terms of race/ethnicity? Please select all that apply

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* 13. How do you identify in terms of gender?

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* 14. How did you hear about Brushes with Cancer

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* 15. If you heard about the program through a friend or family member, please let us know who referred you.

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* 16. Have you participated in BWC or attended the celebratory event?

 

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* 17. If yes, in what program or what capacity did you participate?

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* 18. How are you connected to the person with the cancer diagnosis?

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* 19. Do you have a cancer experience that is not pancreas related? If so, what type?

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* 20. Why are you interested in participating in the program?

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* 21. What is your "twist on cancer?" (Lessons learned and big picture takeaways?)

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* 22. Are you comfortable sharing your story with someone outside of your personal circle? 

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* 23. What is your preferred method of communication?

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* 24. My support system is mostly made up of: 

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* 25. Do you believe your employer would be interested in supporting Brushes with Cancer? If so please provide us with the name and contact information for the person(s) we should be in touch with.

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* 26. Do you anticipate any barriers to participating in Brushes with Cancer?

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* 27. I feel disconnected from the world around me.

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i We adjusted the number you entered based on the slider’s scale.

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* 28. Even around people I know, I don't feel that I really belong.

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i We adjusted the number you entered based on the slider’s scale.

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* 29. I feel so distant from people.

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i We adjusted the number you entered based on the slider’s scale.

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* 30. I have no sense of togetherness with my peers.

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i We adjusted the number you entered based on the slider’s scale.

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* 31. I don't feel related to anyone.

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i We adjusted the number you entered based on the slider’s scale.

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* 32. I catch myself losing all sense of connectedness with society.

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i We adjusted the number you entered based on the slider’s scale.

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* 33. Even among my friends, there is no sense of brother/sisterhood.

Strongly Agree Strongly Disagree
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i We adjusted the number you entered based on the slider’s scale.

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* 34. I don't feel that I participate with anyone or any group.

Strongly Agree Strongly Disagree
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i We adjusted the number you entered based on the slider’s scale.

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* 35. Are there any issues or concerns we should be aware of that may or may not impact your participation, such as physical or emotional challenges that may prevent you from sharing your story with someone new?

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* 36. As part of an ongoing effort to strengthen the impact of our programs, we may collect and analyze participant responses to program applications and evaluations. When analyzing responses, we are interested in trends in our data, rather than the responses of any particular person, and therefore responses will be de-identified for the purpose of data analysis. If you prefer that your responses not be included in data analyses, please check below. Please select Yes if you wish to include your de-identified responses and select No if you wish to not include your responses in future studies.

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