The National Coalition for Cancer Survivorship (NCCS): Survey - Additional Information from Registrants

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Additional Information from Registrants

Thank you for registering with NCCS! We would like to learn more about you, so please take a moment to update your profile by completing this quick survey.

Please enter the email address that you used to register so we can update your record.


*	Email: Required
	Remember me. What's this?

Question - Not Required - I am a (check all that apply):

	Survivor (in treatment)
	Survivor (post treatment)
	Caregiver
	Health Care Professional
	Media
	Other

Question - Not Required - If you chose "Other," please describe:

Question - Not Required - I am interested in (check all that apply):

	Cancer News and Reports
	Cancer Resources (publications, guides, Cancer Survival Toolbox, etc.)
	Connecting with Others
	Taking Action!
	Survivorship Issues During Treatment
	Survivorship Issues Post-treatment
	NCCS/Cancer Community Events

Question - Not Required - Approximately how many other cancer organizations/groups are you currently involved with (i.e. receive regular emails from, donate, volunteer, etc.)?

Question - Not Required - Which of the following actions would you consider taking? (check all that apply)

	Send a letter to my representative through NCCS's web site
	Call my representative about cancer issues
	Visit my representative's District office
	Visit my representative's Capitol Hill office
	Write a "letter to the editor"
	Recruit others to join the network
	Not interested in taking an action

Question - Not Required - Do you read or participate in blogs or online social networking sites (such as MySpace)?

Question - Not Required - I am between the ages of

If you have a personal story about cancer survivorship and would like to share it with us, please provide the following:

Question - Not Required - Phone:

Question - Not Required - Email

I will share my story via the email address above

Spam Control Text: Please leave this field empty