Native Cancer Treatment Journey: Support Bag Request
provided by Native JourneyWoman

Question Title

* 1. What is your name and contact information?

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

* 2. Race/Ethnicity (check all that apply)

American Indian or Alaska Native

Native Hawaiian or Pacific Islander

Asian or Asian American

Hispanic or Latino

Black or African American

White or Caucasian

Other (please specify)

Question Title

* 3. Tribal Affiliation

Question Title

* 4. What is your Tribal Clinic or Urban Indian Clinic?

Question Title

* 5. Name of Tribal/Urban Indian Clinic contact (ie: Patient Navigator, Case Manager)?

Question Title

* 6. Would you like us to send you a Native Cancer Treatment Support Bag?

Yes

Question Title

* 7. Cancer stage (if known)

III

Question Title

* 8. Cancer type

Question Title

* 9. My cancer treatment includes:

Surgery

Chemotherapy

Radiation

Traditional Medicine/Healer

Other (briefly describe)

Question Title

* 10. Additional Patient Needs (We have limited funds and can only send the Support Bag at this time. We will use this information to seek additional funds.)

Basic needs (groceries, utilities)

Prosthesis (such as a bra after breast cancer surgery)

Native Support Group - connection with other Native Cancer Survivors

Phone during treatment

Transportation to/from treatment

Lodging during treatment

Childcare of Eldercare

Other (please specify)

Native Cancer Treatment Journey: Support Bag Requestprovided by Native JourneyWoman

Question Title

* 1. What is your name and contact information?

Question Title

* 2. Race/Ethnicity (check all that apply)

Question Title

* 3. Tribal Affiliation

Question Title

* 4. What is your Tribal Clinic or Urban Indian Clinic?

Question Title

* 5. Name of Tribal/Urban Indian Clinic contact (ie: Patient Navigator, Case Manager)?

Question Title

* 6. Would you like us to send you a Native Cancer Treatment Support Bag?

Question Title

* 7. Cancer stage (if known)

Question Title

* 8. Cancer type

Question Title

* 9. My cancer treatment includes:

Question Title

* 10. Additional Patient Needs (We have limited funds and can only send the Support Bag at this time. We will use this information to seek additional funds.)

Question Title

* 11. Would you like to share anything else with us at this time?

Native Cancer Treatment Journey: Support Bag Request
provided by Native JourneyWoman