Cancer Prevention Study 3 Interest Form

I want to fight back against cancer by participating in

Cancer Prevention Study-3

Please read criteria and check each box to acknowledge the terms of participating.

Help us spread the word! Tell 3 people about CPS-3 and forward this interest form
asking them to also tell 3 people.

CLICK HERE to learn more about CPS3

I will commit to the study long term (which means completing surveys periodically for the next 20-30 years) *

Yes

No

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) *

I have NEVER been diagnosed with cancer

I have been diagnosed with cancer

I have been diagnosed with basal or squamous cell skin cancer

I am between 30–65 years old *

Yes

No

I understand that I must complete the first part of enrollment at my local Relay For Life event (date and time TBD) *

Yes

No

I am willing to provide a confidential waist measurement. *

Yes

No

I am willing to give a small amount of blood (7 teaspoons), collected by a certified, trained phlebotomist. *

Yes

No

I am willing to complete periodic follow-up surveys that will be mailed to my home for the next 20-30 years. *

Yes

No

I am willing to complete a more-detailed survey at my home after my local event, which will finalize my enrollment in the study. This survey will ask detailed questions regarding medical history, lifestyle, and behaviors. *

Yes

No

Would you like a reminder sent to you closer to Relay? Please check your preferred method of communication *

Phone

Email

Mail

What Relay For Life event do you participate in? Answer N/A if you are not currently a Relay For Life participant. *

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

County you reside in *

Zip Code *

Phone Number *

Email Address *