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:

Zip Code

Highest Level of Education

Number within Household:

Number of generations within household, i.e., Grandparent(s) raising grandchildren

Household income:

What type of breast cancer were you diagnosed with:

What stage?

Was your cancer discovered during screening ?

Was your cancer able to be felt on physical examination?

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?

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.