Contact Information

The following information will allow us to contact you.

Full Name

Address (required)

Phone:

Email

Preferred method of communication:
EmailPhone

Question

The following information you share will give us an insight into what types of experiences and stories you will bring to the program as a patient teacher.

1. At which hospital/health care centre did you receive the majority of your treatment and care?

St. Michael’s HospitalSunnybrook HospitalPrincess Margaret/University Health NetworkOther-specify below:

2. What type of cancer do you have?

3. What was your age at diagnosis?

4. What is your current age?

5. What types of treatments did you receive? (please select all that apply)

Mastectomy SurgeryLumpectomy SurgeryBreast reconstruction SurgeryColorectal surgeryPlease list any surgeries

ChemotherapyRadiationEndocrine therapy (oral pills)Adjuvant TherapiesOther - specify:

6. Which of the following best describes your gender identity?

FemaleMaleIntersexTransgender - female to maleTransgender - male to femaleDo not knowPrefer not to answerOther - please specify

Preferred pronouns

7. Which of the following best describes your racial or ethnic group identity?

Asian – East (e.g. Chinese, Japanese, Korean)Asian - South (e.g. Indian, Pakistani, Sri Lankan)Asian - South East (e.g. Malaysian, Filipino, Vietnamese)Black - African (e.g. Ghanaian, Kenyan, Somali)Black – Caribbean (e.g. Barbadian, Jamaican)Black – North American (e.g. Canadian, American)First NationsIndian - Caribbean (e.g. Guyanese with origins in India)Indigenous/Aboriginal – not included elsewhereInuitLatin American (e.g. Argentinean, Chilean, Salvadoran)MétisMiddle Eastern (e.g. Egyptian, Iranian, Lebanese)White – European (e.g. English, Italian, Portuguese, Russian)White – North American (e.g. Canadian, American)Do not knowPrefer not to answer

8. What is your current profession?

9. Briefly tell us why you are interested in becoming a patient teacher.

10. How did you hear about becoming a patient teacher? (please select all that apply)

Patient as Teacher program websiteHospital Patient and Family Advisory CommitteeCIBC Breast Cancer CentreCommunity organizationFrom a surgeon/physician/health care professionalFrom friends/familyFrom a patient teacherOther – specify:

11. Have you ever volunteered or shared your cancer story before?

12. What does your support system look like?

By filling out this form I consent to being contacted with regards to becoming a patient teacher

Yes, I agree

Please indicate whether you consent to your online application form to be part of the Patients as Teachers study. Please see detailed informed consent form.

Yes, I consentNo, I do not consent