The American Cancer Society: Survey - RFL FY09 IL Western Region CPS 3 Survey

RFL FY09 IL Western Region CPS 3 Survey

*1.

Question - Required - I am between the ages of 30 and 65 years

*2.

Question - Required - I have NEVER been diagnosed with cancer (no personal history with cancer) (basal or squamous cell skin cancers are not included in the definition of "personal history with cancer" because they are not considered malignant, so you may participate if that was your diagnosis)

*3.

Question - Required - I will commit to the study long term (completing surveys every-other-year for 20 years)

*4.

Question - Required - I understand that I must complete phase 1 of enrollment at Relay For Life of Sangamon County at IL State Fairgrounds on June 20th, 2009, followed up with phase 2 at home after Relay.

*5.

Question - Required - I am willing to provide a confidential waist measurement.

*6.

Question - Required - I am willing to give a small amount of blood, collected by a certified, trained phlebotomist.

*7.

Question - Required - I am willing to complete a detailed survey after Relay regarding medical history, lifestyle, and behaviors

8.

Please provide your personal information below:


*	First Name: Required
*	Last Name: Required
*	Email: Required
*	Street 1: Required
	Street 2:
*	City: Required
*	State / Province:	State / Province: Required
*	ZIP / Postal Code: Required
*	Phone Number: Required
	Please email me event-related information so I can participate successfully.
	Yes, I would like to receive postal mail regarding my participation in this American Cancer Society event.

9.

Question - Not Required - Would you like a reminder sent to you closer to Relay? Please select your preferred method of communication. Phone
Email
Mail