Survey - Survivor 2 Survivor for Patients to Fill Out

*1.

Question - Required - Today's Date:

2.

Contact Information

*

Name:

First Required	Last Required

*

Email: Required

Yes, I would like to receive e-mail from Bladder Cancer Advocacy Network

Yes, I would like to receive postal mail from Bladder Cancer Advocacy Network

*3.

Question - Required - Are you a:

Patient

Survivor

Caregiver/Family Member

Medical Facility/Social Worker

Other

*4.

Question - Required - Person diagnosed with bladder cancer (Patient first name)

5.

Question - Not Required - Patient last name

*6.

Question - Required - Patient age:

7.

Question - Not Required - If you are a caregiver or loved one to the person who has bladder cancer, what best describes your relationship?

*8.

Question - Required - Patient gender:

Male

Female

*9.

Question - Required - What time zone is the Patient in?

10.

Question - Not Required - Generally speaking, what would be the best times for an S2S call from the volunteer?

	Mornings (9-12 noon)
	Afternoons (12-4 pm)
	Evenings (4-8 pm)

*11.

Question - Required - Address:

(Maximum response 255 chars, approx. 5 rows of text)

*12.

Question - Required - City:

*13.

Question - Required - State:

*14.

Question - Required - Zip Code:

*15.

Question - Required - Preferred Phone Number:

*16.

Question - Required - What is the bladder cancer diagnosis?

17.

Question - Not Required - Can you provide more details about diagnosis (i.e. T1)? Please enter them here:

*18.

Question - Required - What would the patient like to discuss with the S2S volunteer?
Please make at least 1 selection from the choices below.

	Caregiver conversation
	Cystoscopy surveillance
	TURBT
	BCG
	Cystectomy - evaluating options, managing diversion
	Immunotherapy
	Chemotherapy
	Radiation
	Surgery Process/Recovery Expectations
	Other/Unsure

19.

Question - Not Required - If you would like to talk about the bladder removal surgery (radical cystectomy): what urinary diversions are you considering? You may select more than one.

	Ileal Conduit (bag)
	Neobladder
	Indiana Pouch

20.

Question - Not Required - If you would like to talk about diversion management after surgery: what urinary diversion do you have?

21.

Question - Not Required - Do you have the procedure or treatment that you would like to talk to a volunteer about already scheduled? If so, when?

22.

Question - Not Required - Add any additional comments/notes that you would like the volunteer to know before they call you?