GRASSROOTS – LOCAL DATA COLLECTION EFFORT

The Mya Lin Terry FoundationCancer Cluster Investigation Questionnaire

Introduction

Thank you in advance for participation. Concerned parents are investigating cases of pediatric cancer, among individuals who were diagnosed on or after January 1, 2001 at age 19 or younger and have spent a substantial amount of time in Monmouth County, New Jersey. We are attempting to identify potential cluster(s). Parents or guardians of affected children, are asked to provide details about their child’s diagnosis, medical history, and possible exposures experienced by their children. This questionnaire should take between 15 and 30 minutes to complete. Please respond to each question by providing the detail requested or selecting your response. NOTE: This questionnaire is for pediatric cancer patients who have lived, or have spent a substantial amount of time in Monmouth County, New Jersey only.

This questionnaire will be open for response, until July 15, 2018. Note: This survey is best viewed on a desktop, vice mobile app.

If you have any questions or concerns about the survey, please call us at 732 517-0697 or [email protected].

Interviewee Information

Privacy Authorization Form
**Authorization for Use or Disclosure of Protected Health Information **

Privacy Authorization Form **Authorization for Use or Disclosure of Protected Health Information ** I hereby authorize The Mya Lin Terry Foundation to use and disclose the protected health information I am providing in response to this online survey in support of a pediatric cancer cluster study pursuit in Monmouth County, New Jersey. This consent remains in effect for all past, present, and future periods. Signature of patient or personal representative Printed name of patient or personal representative and his or her relationship to pediatric cancer patient Date

* Indicates required field

1. Name *

First

Last

2. What is the best phone number to contact you? *

3. Email *

4. What is the best way to contact you if we have questions or need clarification? *

5. What is your relationship to the child? *

Child information

6. Child’s name *

First

Last

7. Child’s date of birth *

8. Is child adopted? *

Yes No Don’t know/not sure

9. Child’s sex *

If other, please specify *

10. Child’s vital status *

11. Child’s race: *

If other, please specify *

12. Child’s ethnicity *

13. Date of diagnosis (month/year) *

14. Child’s age at diagnosis (years, or months if child was under age 1) *

Names of physician(s) and facility where the child was first diagnosed.

15. Physician: *

16. Facility: *

17. If needed, may we contact this person? *

Yes No

Approximate date when child first developed symptoms (month/year) *

18. Location/anatomical site of primary tumor *

Residence and School Locations

20. Where did your child live when he or she was diagnosed?

Street address (do not use a PO Box number) *

City *

County *

State *

ZIP code *

Dates lived in residence (month/year to month/year) *

21. Did your child live anywhere else before he or she was diagnosed? *

Yes No Don’t know/not sure

Street address #1 (do not use a PO Box number) *

City *

County *

State *

ZIP code *

Dates lived in residence (month/year to month/year) *

Street address #2 (do not use a PO Box number) *

City *

County *

State *

ZIP code *

Dates lived in residence (month/year to month/year) *

Street address #3 (do not use a PO Box number) *

City *

County *

State *

ZIP code *

Dates lived in residence (month/year to month/year) *

22. List schools or childcare facilities that your child attended before being diagnosed (if they did not attend child care or school, leave blank and go to the next question

Street address #1 (do not use a PO Box number) *

City *

County *

State *

ZIP code *