Initial Intake Survey

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* 1. Do you identify as Asian/Native Hawaiian/Other Pacific Islander?

Yes

Other/Mixed

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* 2. What is your ethnicity?

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* 3. What is your geographical location (zip/postal code)?

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* 4. What is your gender?

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* 5. What is the highest education level you obtained?

Did not finish high school

High school diploma or GED

Some college

Vocational/trade degree

Associate’s degree (2-year degree)

Bachelor’s degree (4-year degree)

Graduate degree (MD, Masters, JD, PhD, etc.)

Other (please specify)

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* 6. What generation immigrant are you?

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* 7. What country were you born in?

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* 8. For how many years have you lived in the USA?

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* 9. Are you proficient enough in English to complete an interview on this topic?

Yes

Other. Please clarify here:

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* 10. If you selected “no” or “other,” what language would you need an interpreter for, if needed? We will find one for you!

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* 11. What category best describes your total yearly household income before taxes (include employment, welfare, investments, everything)?

Less than $5,000

$5,000 - $9,999

$10,000 - $14,999

$15,000 - $19,999

$20,000 - $29,999

$30,000 - $39,999

$40,000 - $49,999

$50,000 - $59,999

$60-000 - $74,999

$75,000 - $99,999

$100,000 - $124,999

$125,000 - $149,999

$150,000 or more

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* 12. Were you diagnosed with hereditary breast and ovarian cancer through genetic testing (ex: BRCA1, BRCA2)?

Yes

Other. Please clarify:

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* 13. How old are you right now?

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* 14. Are there any other access needs that I can help you meet during the interview (ex: speak loudly in interviews, etc.)?

Yes. Indicate here:

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* 15. Please sign this consent form to indicate that you understand and agree to participate in the study: https://drive.google.com/file/d/1q8eMEAj1Fgaee3PbUuuutBcKofVutUL1/view?usp=sharing

Please click on the link above and download the form. After signing it, please upload it here:

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 16. Please provide your name, phone number, and email for contacting to schedule an interview:

Name

Phone Number

Initial Intake Survey

Question Title

* 1. Do you identify as Asian/Native Hawaiian/Other Pacific Islander?

Question Title

* 2. What is your ethnicity?

Question Title

* 3. What is your geographical location (zip/postal code)?

Question Title

* 4. What is your gender?

Question Title

* 5. What is the highest education level you obtained?

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* 6. What generation immigrant are you?

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* 7. What country were you born in?

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* 8. For how many years have you lived in the USA?

Question Title

* 9. Are you proficient enough in English to complete an interview on this topic?

Question Title

* 10. If you selected “no” or “other,” what language would you need an interpreter for, if needed? We will find one for you!

Question Title

* 11. What category best describes your total yearly household income before taxes (include employment, welfare, investments, everything)?

Question Title

* 12. Were you diagnosed with hereditary breast and ovarian cancer through genetic testing (ex: BRCA1, BRCA2)?

Question Title

* 13. How old are you right now?

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* 14. Are there any other access needs that I can help you meet during the interview (ex: speak loudly in interviews, etc.)?

Question Title

* 15. Please sign this consent form to indicate that you understand and agree to participate in the study: https://drive.google.com/file/d/1q8eMEAj1Fgaee3PbUuuutBcKofVutUL1/view?usp=sharing

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* 16. Please provide your name, phone number, and email for contacting to schedule an interview:

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* 17. Indicate your general availabilities (these will be further discussed when scheduling the interview):