Southwest Florida Collaborative Member Profile 2019

Welcome! We value your interest and willingness to make a difference in your local cancer community.

Completing a Member Profile will take about 5 minutes and will better facilitate your involvement in the Regional Cancer Control Collaborative.

There is no cost for membership and no information will be shared with a third party.

Question Title

1. Please provide the following information:

Name:

Organization:

Email Address:

Phone Number:

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2. Please select which of the following sectors best represents you or your organization:

Community-based Non-Profit Organization

Family Member

For-Profit Organization

Government

Health Provider

Hospital and/or Cancer Center

Insurer or Managed Care System

Pharmaceutical

Student

Survivor

University

Other (please specify)

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3. Please select which of the following role or title best describes you:

Caregiver

Community Health Care Worker

Dentists/Dental Hygienist

Dietitians/ Nutritionist

Epidemiologist

Health Administrator

Health Education Specialist

Home Health Aide

Interested Community Member

Marriage and Family Therapist

Medical Assistant

Navigator

Nursing Assistant

Nurse

Pharmacist

Physical Therapist

Physician

Physician Assistant

Professional Counselor

Researcher

Social Worker

Survivor

Student

University Academic

Volunteer

Other (please specify)

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4. Please select the county in which you primarily work:

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5. Please select your gender:

Male

Female

Transgender

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6. Please select your race:

African American/Black

Caucasian/White

American Indian/Alaskan Native

Asian

Multiracial

Native Hawaiian/Other Pacific Islander

Other (please specify)

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7. Please select your ethnicity:

Hispanic/Latino

Non-Hispanic/Latino

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8. Please select your highest level of education:

Less than High School

High school or equivalent

Technical school

Some college

Associate degree

Bachelor degree

Graduate degree

Post graduate degree

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9. Please select your age range:

18-24

25-30

31-40

41-50

51-60

61-70

71+

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10. Please indicate your area(s) of interest and expertise:

	Interest	Expertise
Training ideas and speakers	Training ideas and speakers Interest	Training ideas and speakers Expertise
Breast cancer screening	Breast cancer screening Interest	Breast cancer screening Expertise
Cervical cancer screening	Cervical cancer screening Interest	Cervical cancer screening Expertise
Colorectal cancer screening	Colorectal cancer screening Interest	Colorectal cancer screening Expertise
Data and evaluation	Data and evaluation Interest	Data and evaluation Expertise
Disparities	Disparities Interest	Disparities Expertise
Early detection efforts	Early detection efforts Interest	Early detection efforts Expertise
Education	Education Interest	Education Expertise
Epidemiology	Epidemiology Interest	Epidemiology Expertise
Florida Cancer Plan	Florida Cancer Plan Interest	Florida Cancer Plan Expertise
Genetics	Genetics Interest	Genetics Expertise
Healthy weight	Healthy weight Interest	Healthy weight Expertise
Human Papilloma Virus (HPV)	Human Papilloma Virus (HPV) Interest	Human Papilloma Virus (HPV) Expertise
Lung cancer screening	Lung cancer screening Interest	Lung cancer screening Expertise
Native American Indian	Native American Indian Interest	Native American Indian Expertise
Palliative care	Palliative care Interest	Palliative care Expertise
Policy and advocacy	Policy and advocacy Interest	Policy and advocacy Expertise
Prevention efforts	Prevention efforts Interest	Prevention efforts Expertise
Sun safety	Sun safety Interest	Sun safety Expertise
Survivorship	Survivorship Interest	Survivorship Expertise
Tobacco	Tobacco Interest	Tobacco Expertise

Other (please specify)

Question Title

11. Each regional collaborative has different committees and workgroups.

Please select the committee you are interested in joining. The chairperson or local coordinator will contact you.

Survivorship

Screening and Prevention

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1. Please provide the following information:

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2. Please select which of the following sectors best represents you or your organization:

Question Title

3. Please select which of the following role or title best describes you:

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4. Please select the county in which you primarily work:

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5. Please select your gender:

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6. Please select your race:

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7. Please select your ethnicity:

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8. Please select your highest level of education:

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9. Please select your age range:

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10. Please indicate your area(s) of interest and expertise:

Question Title

11. Each regional collaborative has different committees and workgroups.Please select the committee you are interested in joining. The chairperson or local coordinator will contact you.

11. Each regional collaborative has different committees and workgroups.

Please select the committee you are interested in joining. The chairperson or local coordinator will contact you.