YSC Peer to Peer Support Volunteer Update Survey

YSC Peer to Peer Support Volunteer Update

1. Demographics

Demographics Name
Company
Address 1
Address 2
City
State
Zip
Email Address

2. Please provide your preferred daytime telephone number:

Please provide your preferred daytime telephone number:

3. Are you a/an

Are you a/an Early stage breast cancer patient currently in treatment

Breast cancer survivor (post treatment and no evidence of disease)

Young woman living with metastatic breast cancer

Caregiver/co-survivor

Young woman at high risk for developing breast cancert

4. Where do you live?

Where do you live? Northeast (NY, CT, RI, VT, MA, ME, NH)

Mid-Atlantic (NJ, DE, MD, DC, PA, WV, VA)

South (NC, SC, GA, FL, KY, TN, MS, AL, AK, LA)

Midwest (MN, IA, IL,WI, IN, OH, MI)

Central (ND, SD, NE, KS, OK, CO, TX, MO)

West (CA, MT, ID, WY, NV, UT, AZ, NM)

Pacific Northwest (WA. OR)

Puerto Rico, Hawaii, Alaska

Other, please specify

Enter an answer

5. With what racial/ethnic group do you most identify?

With what racial/ethnic group do you most identify? Hispanic/Latina

African-American (Black)

American Indian or Alaska Native

White (Caucasian)

Asian or Pacific Islander

Other, please specify

6. What was your relationship status at the time of your diagnosis?

What was your relationship status at the time of your diagnosis? Single

Single and dating

In a partnered relationship but not married

Married

Seperated or divorced

Other, please specify

7. Your current age:

Your current age: Under 20

20-29

30-39

40-49

50+

8. Your age at initial diagnosis:

Your age at initial diagnosis:

9. How do you identify your sexual orientation?

How do you identify your sexual orientation? Heterosexual

Homosexual

Lesbian/Gay

Bisexual

Transgendar

10. My prior peer mentoring training/experience includes:

My prior peer mentoring training/experience includes: YSC SurvivorLink

Y-Me/Network of Strength

Living Beyond Breast Cancer

Imerman Angels

Other, please specify

11. What type of breast cancer was part of your diagnosis?

What type of breast cancer was part of your diagnosis? Ductal

Invasive

Inflammatory

Other, please specify

12. What stage of breast cancer was part of your diagnosis?

What stage of breast cancer was part of your diagnosis?

13. Please provide details relating to your type and/or stage of diagnosis:

Please provide details relating to your type and/or stage of diagnosis:

14. Estrogen Receptor (ER)

Estrogen Receptor (ER)

15. Progesterone Receptor (PR)

Progesterone Receptor (PR)

16. Her2Neu

Her2Neu

17. My treatment included:

My treatment included: Surgery

Chemotherapy

Radiation

Targeted therapy (hormonal, aromatase inhibitor)

All of the above

Other, please specify

18. Do you have a family history of breast cancer?

Do you have a family history of breast cancer?

19. Have you undergone genetic testing?

Have you undergone genetic testing?

20. Did you consider a preventative/prophylactic mastectomy?

Did you consider a preventative/prophylactic mastectomy?

21. Did you have a prophylactic/preventive mastectomy?

Did you have a prophylactic/preventive mastectomy?

form {display:none;} #jserror {text-align:center;margin-top:50px;}Javascript is required for this site to function, please enable.