Part 2: Data for Grant Fundraising

Data for Fundraising Form
There’s Power In Our Voices: PART 2

Data for Fundraising

Members, please consider answering the following questions. Your answers will be anonymous and neither will there be a means to identify your personal profile with this information. This data will be helpful in securing future grant funding for the CBBC.
I am a:

SurvivorCaregiverFamily MemberSupporter
Zip Code
Highest Level of Education

Less than High SchoolHigh School Grad/GEDBachelor's DegreeMaster's DegreeTerminal Degree, JD/EdD,PhD or other
Number within Household:

SelfSelf and SpouseParents & DependentsSingle Parent & Dependents
Number of generations within household, i.e., Grandparent(s) raising grandchildren
Household income:

Less than $25,000$25,000 - $60,000$60,000 - $90,000$90,000 - $120,000$120,000 - $175,000$175,000 - $250,000More than $250,000
For Breast Cancer Survivors
What type of breast cancer were you diagnosed with:

invasive ductalinvasive lobularintraductal/DCISOtherI don't know
What stage?
Was your cancer discovered during screening ?

YESNO
Was your cancer able to be felt on physical examination?

YESNO
What treatments did you receive and for how long? Chemotherapy? Radiation therapy? Endocrine therapy (ex Tamoxifen or an Aromatase Inhibitor?)
Were you offered genetic testing?

YESNOYes it was offered and I received genetic testing
What were your surgical options? Which did you decide? (ex mastectomy (one side or both sides?), Mastectomy with reconstruction, lumpectomy)
Have you had a recurrence of cancer since your first diagnosis? Are you currently without evidence of disease if you had a recurrence?
What short and/or long term after effects do you experience as a result of your cancer and/or your cancer treatments?
Describe your typical weekly diet and exercise.
Should be Empty: