FORCE Partnership Program Questionnaire

The Partnership Program is a community of organizations focusing on cancer advocacy, research, education, and support working together for people and families facing hereditary cancer.

1. Please tell us about your organization

Organization Name

Organization Website URL

Street Address

City

State/Province

Zip/Postal Code

Country

Phone Number

Mission Statement

Logo (Please upload as a .jpeg, .jpg, or .png file)

Please list your social media tags in the spaces provided below. If you are using platforms not shown, please use the other field and list them in the space provided.

Facebook URL

Instagram URL

LinkedIn URL

Other social media URL

2. Please provide your contact information

Primary Contact

First Name

Last Name

Title

Phone

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Secondary Contact

First Name

Last Name

Title

Phone

Other Contact

First Name

Last Name

Title

Phone

3. What is your geographic focus?

National (United States)Regional United States (Please list region below.)State or local (Please list state/city below.)Outside of the United States (Please list country below.)Global

State or country if applicable (please specify)

4. Is your organization designated as a nonprofit organization?

YesNo

5. What types of cancer do you focus on? (Please select all that apply.)

Breast Cancer

Gastrointestinal cancer (colorectal, gastric, pancreatic)

Gynecologic cancer (endometrial, fallopian tube, ovarian)

Melanoma

Urogenital cancer (bladder, kidney, prostate)

Thyroid cancer

Hereditary Cancer

Other cancer(s)

All cancers

Please specify other cancers

Please specify other topics

Please specify other important components

Please record the URL for navigation support on your website.

9. Do any of these audiences comprise more than 25% of your constituency? (Please select all that apply.)

Please specify other audiences

10. What proportion of your constituents identify with the following groups?

Young adults with cancer

Racial minorities

Ethnic minorities

Gender minorities

Religious minorities

People with disabilities

People with limited literacy skills

People for whom English is a second language

People who live in rural areas

People living at or below the poverty level

People with limited access to internet

People with limited access to healthcare

Signature

(Please type full name)

Contact Information

Behavioral health, emotional support, or wellness	Clinical Trials
Clinical Services	Disparities
Family or Caregiver Issues	Fertility Preservation or Family Planning
Financial Issues	Genetics
Health Equity/Access to Care	Post-treatment/Survivorship
Race, ethnicity, sexual and gender minorities	Research
Screening or prevention	Treatment
Other

Public Policy	Awareness
Education	Peer or emotional support
Guideline or consensus development	Conducting research
Training consumers to participate in the research process	Providing grants for research
Career development	Providing financial support to patients
Providing other physical support to patients (e.g., transportation, child care services, delivering meals, etc.)	Providing navigation support to patients (e.g., directing them to resources, information or services)
Providing direct healthcare services to patients	Other