This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9]|800|811)$?)\s*(?:[.-]\s*)?([2-9]1[02-9]|[2-9][02-9]1|[2-9][02-9]{2})\s*(?:[.-]\s*)?([0-9]{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^((((\+44|0044)\s?\d{4}|$?0\d{4}$?)\s?\d{3}\s?\d{3})|(((\+44|0044)\s?\d{3}|$?0\d{3}$?)\s?\d{3}\s?\d{4})|(((\+44|0044)\s?\d{2}|$?0\d{2}$?)\s?\d{4}\s?\d{4}))(\s?\#(\d{4}|\d{3}))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

/^(\d|[01]\d|(2[0-3]))(:[0-5]\d){2}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^[0-9]{4,9}$/

/^\d{5}(-\d{4})?$/

jKTwuYPdmpojtxpnvtQddCHGryQrkFUGU66VggWMwP7eYQ8P7oJsVbk6CcMLiw64NnYEeikQDpCFh

Community Champion Information Sheet

Returning?

A A A

We are very pleased to have you involved in the Massey Cancer Center Community Champion Program.

Please complete the form below so that we can keep track of our Community Champions.

Thank you!

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

reset

Do we have your permission to contact you via text message?

* must provide value

Yes

reset

What is an alternative phone number to reach you?

Street Address

* must provide value

Street Address Line 2
(i.e., Apt, Unit #)

City

* must provide value

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

reset

The following questions ask for information about you. This information is used to capture representativeness of the community among our champions. Your information will be kept private amongst the Community Champion Program team.

This data will assist the team to distribute specific requests for research or health education projects to representative champions. (E.g., the team receives a request for champions to review recruitment materials for a prostate cancer study - we distribute this opportunity to all identifying males).

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

reset

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

reset

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

reset

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

reset

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

Prefer not to answer

reset

Have you ever been diagnosed with cancer?

* must provide value

Yes

reset

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

Prefer not to answer

reset

Have you previously participated in one of Massey Cancer Center's champion programs?

* must provide value

Yes

Don't Know

reset

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.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.