GO2 for Lung Cancer

Thank you for your interest in volunteering with GO2 for Lung Cancer!

This form is for patients, survivors, caregivers, loved ones, and other community members who have experienced lung cancer and are interested in supporting the work of GO2.

If you are interested, please continue. We expect the survey to take about 10 minutes. The information requested helps us to match you with the best opportunities for you, and to understand what kind of training, support, and resources you may need to support your involvement with the organization. We will not use the information in any other way without your explicit permission.

If you have any questions or concerns, please email our Senior Manager of Community Engagement, Susan Smedley, ssmedley@go2.org.

Please provide your contact information

* Required Field


*	First Name: Required
*	Last Name: Required
*	Email: Required
	Street 1:
	Street 2:
	City:
	State / Province:
	ZIP / Postal Code:
	Country:
	Phone Number:
	Occupation:
	Date of Birth:	Date of Birth:
	Yes, I would like to receive email updates and the GO2 for Lung Cancer's Monthly Measure, e-newsletter.

*

Question - Required - How would you best characterize yourself?

Question - Not Required - Languages spoken (please separate by comma)

Cancer History

These questions are designed to give us information about the type of cancer and treatments that you/your loved one had, as certain opportunities may want people who have had experiences with specific types of cancers or treatments. It is OK if you do not know the answers.

If you are a caregiver/loved one, please answer these questions for the primary person that you cared for.

Question - Not Required - What type of lung cancer were you/your loved diagnosed with?

Question - Not Required - If "other" please specify

Question - Not Required - Date of diagnosis

Question - Not Required - Age of your diagnosis/your loved one's diagnosis

Question - Not Required - What stage lung cancer were you/your loved one diagnosed with?

Question - Not Required - Lung cancer stage (please specify)

Question - Not Required - How was your lung cancer found?

Question - Not Required - Have you had a recurrence?

Question - Not Required - What type of treatments did you/your loved one have? (Check all that apply)

	Ablation
	Chemotherapy
	Clinical Trials
	I don't know
	Immunotherapy
	Radiation
	Surgery
	Targeted Therapy

Question - Not Required - Chemotherapy Type (please specify)

Question - Not Required - Immunotherapy Type (please specify)

Question - Not Required - Targeted Therapy (please specify)

Question - Not Required - Clinical Trials Type (please specify)

Question - Not Required - Did you/your loved one have molecular testing/biomarker testing? If yes, which biomarker was identified, if any?

	ALK
	BRAF
	EGFR
	I do not know if I had testing
	KRAS
	MET
	No, I did not have testing
	RET
	ROS1
	Yes, I had testing

Question - Not Required - Have you had any of the following experiences?

	Experienced stigma
	Issues with insurance or cost of care
	Lived alone at the time of diagnosis
	Lived with family at the time of diagnosis
	Military service or armed forces veteran
	Quality of life Issues
	Received a second opinion
	Received palliative care
	Worked during treatment

Ambassador Interest

These questions will allow you to share what types of volunteer opportunities are most interesting to you, as well as what unique experiences, passions, and qualifications you have - both from your personal experience and/or professional life - that might support or influence your work as an Ambassador for GO₂.

Question - Not Required - I am interested in being contacted for the following volunteer opportunities

	Administrative support
	Events and/or fundraising
	Opportunities within our Excellence in Screening and Care health care facilities
	Patient and/or community education
	Policy advocacy
	Research advocacy and/or opportunities to support our Patient Registry
	Serving as a Phone Buddy or Peer Mentor
	Sharing my story with the media, industry partners, and/or the GO2 Community

Question - Not Required - Are you willing to travel for volunteer opportunities, if needed? (Assume that travel costs will be covered.)

Question - Not Required - Volunteer opportunities travel (please specify)

Question - Not Required - Please include any personal or professional experiences that may be relevant to your volunteer work. (There are no right or wrong answers.)

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

Question - Not Required - Is there anything else we should know about you and/or your interest in GO2 for Lung Cancer's Ambassador Program?

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

Question - Not Required - Have you previously volunteered as a lung cancer advocate or volunteer? Please list any prior opportunities that you have participated in. (Prior experience is NOT required.)

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

GO2 for Lung Cancer Ambassador Survey