Personal Background

Are you applying for this grant for a prosthetic eye due to uveal melanoma or choroidal melanoma?

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* 1. Are you applying for this grant for a prosthetic eye due to uveal melanoma or choroidal melanoma?

Contact Information

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* 2. Contact Information

What is the best method to get in touch with you for follow-up?

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* 3. What is the best method to get in touch with you for follow-up?

What is your gender?

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* 4. What is your gender?

In what year were you born? (enter 4-digit birth year; for example, 1976)

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* 5. In what year were you born? (enter 4-digit birth year; for example, 1976)

Marital status:

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* 6. Marital status:

How many children do you have?

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* 7. How many children do you have?

Have you applied to the OMF for any assistance before (TAG or PAP)?

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* 8. Have you applied to the OMF for any assistance before (TAG or PAP)?

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