What is your First name?
* must provide value
What is your Last name?
* must provide value
What is the best phone number to reach you?
* must provide value
What type of phone numbers is this?
* must provide value
Cell
Home (Landline)
Work
Do we have your permission to contact you via text message?
* must provide value
Yes
No
What is an alternative phone number to reach you?
Street Address
* must provide value
Street Address Line 2
(i.e., Apt, Unit #)
State
* must provide value
Zip code
* must provide value
What is your email address?
* must provide value
Would you like to be added to the Massey Cancer Center Community Champion Program newsletter?
* must provide value
Yes
No
What is your age?
* must provide value
What is your biological sex assigned at birth?
* must provide value
Male
Female
Intersex
Prefer not to answer
What is your gender identity?
* must provide value
Female (includes cis- or transgender female)
Male (includes cis- or transgender male)
Non-binary
Gender fluid
Intersex
Agender
Other
Prefer not to answer
You selected "Other" for gender identify. Please specify.
What is your race/ethnicity?
[Please select all that apply]
* must provide value
Black/African American
White/Caucasian
Hispanic/Latino
Asian
Other
Prefer not to answer
You selected "Other" for race/ethnicity. Please specify.
What is your preferred language?
* must provide value
English
Spanish
Other
Prefer not to answer
What languages are you fluent in?
* must provide value
English
Spanish
Other
Prefer not to answer
Please specify other language(s):
What is the highest level of education you have completed?
* must provide value
Less than high school
High school diploma or GED
Associate degree
Bachelor's degree
Master's degree
Professional degree (example: MD, DDS, DVM, JD)
Doctorate degree (example: PhD, EdD)
Other
Prefer not to answer
You selected "Other" for education. Please specify.
Which best describes your work arrangements?
* must provide value
Working full-time
Working part-time
Full or part-time student
Retired
Never worked
Unemployed/looking for work
Disabled/on disability
Prefer not to answer
What do you do for work?
* must provide value
What did you do for work prior to retirement?
* must provide value
Have you ever participated in a clinical trial? (i.e., a study where you received medicine)
* must provide value
Yes
No
Prefer not to answer
Have you ever been diagnosed with cancer?
* must provide value
Yes
No
What type of cancer were you diagnosed with?
[Please select all that apply]
* must provide value
Breast
Colorectal
Lung
Prostate
Cervical
Skin
Other
You selected "Other" for cancer type. Please specify.
Do you consider yourself a caregiver for a family member or friend?
* must provide value
Yes
No
Prefer not to answer
Have you previously participated in one of Massey Cancer Center's champion programs?
* must provide value
Yes
No
Don't Know
Which Massey Cancer Center champion program(s) did you previously participate in?
(check all that apply)
Petersburg- Breast 1
Richmond- Breast 1 (Sister's network)
Emporia- Breast 1 (YMCA)
Lawrenceville- Breast 1 (CRRC)
Petersburg- Colorectal 1 (Pathways)
Lawrenceville- Colorectal 1 (CRRC)
Richmond- AHEC LHP
Please tell us briefly how you became involved in the champion program.
* must provide value
These are the cancers that are most impacting our region.
Please indicate the Cancer Type(s) that interest you:
* must provide value
Breast
Colorectal
Lung
Prostate
Cervical
Other
You selected "Other" for the type of cancer that interest you. Please specify.
What are your preferred methods for receiving Community Champion Program training?
[Please select all that apply]
* must provide value
Online (on my own time)
Online (live with an instructor and other participants)
In-Person (within my community)
In-Person (VCU campus)
Prefer not to answer
Community Champions will provide community member and patient perspectives to inform Massey Cancer Center research.
Which of the following Research Projects interest you?
[Please select all that apply]
* must provide value
Article Review and Feedback
Grant Application Review and Feedback
Help to Write Plain Language Research Summaries for the Community
Material Review and Feedback (i.e., recruitment, handouts)
Attend Research Meetings
Sharing Research Findings (i.e., word of mouth, flyers)
Recruit for Research Studies/Clinical Trials
Talk about Your Experiences with Cancer
Travel to Research Conferences
Other
You selected "Other" for Research Activities that interest you. Please specify.
Community Champions will engage in community education activities as Massey Cancer Center community liaisons.
Which of the following Community Education interest you?
[Please select all that apply]
* must provide value
Health Fair
Presentation
Trust Building with the Community
Developing Education Materials
Conduct House Chats
Identify Community Needs and Resources
Share Information via Social Media (i.e., share post, FaceBook Live)
Share Information Other Ways (i.e., flyers within community)
Refer for Screenings
Health Program Development
Other
You selected "Other" for Community Education Activities that interest you. Please specify.
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