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Treatment Study - Intake Form

Thank you for your interest in the research study, Hereditary Breast Cancer Treatment Study (Treatment Study for short).

The purpose of the Treatment Study is to collect information on hereditary breast cancers in individuals with ATM, CHEK2 and PALB2 mutations. Our goal is to understand how these cancers are discovered; how these cancers develop and physically affect women; and how these cancers are treated. The study will look at the 5- and 10-year outcomes of ATM-, CHEK2-, and PALB2-associated breast cancer for all participants to learn about factors that may predict cancer survival. The study uses questionnaires to collect information about breast cancer diagnosis, treatment, and genetic testing history. We will also request your medical records from the hospitals where you received care.

Please complete the following intake form to confirm your eligibility and proceed with enrolling in the study. Your responses will be saved in our secure research database called REDCap (Research Electronic Data Capture) stored on Women's College Hospital servers (Toronto, Canada).

If you have any questions for the study team or would prefer to share this information by email or phone, please contact us at TreatmentStudy@wchospital.ca or 416-323-6400 x5125 or x2749.

The option "" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?

Please confirm that you meet all eligibility criteria as follows:

You were diagnosed with a pathogenic or likely pathogenic ATM, CHEK2, or PALB2 mutation (i.e. not a VUS)

* must provide value

Yes No

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Please specify

* must provide value

ATM

CHEK2

PALB2

You were diagnosed with breast cancer in the year 2000 or later

* must provide value

Yes No

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Breast cancer was your first diagnosis of cancer

* must provide value

Yes No

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You were assigned female sex at birth

* must provide value

Yes No

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You can read and understand English

* must provide value

Yes No

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It looks like you are eligible to participate in the Treatment Study. If you would like to learn more about the study, please complete the rest of this form. Once you are done, please click "Submit" at the bottom of the page.

Based on your responses, you are not eligible to participate in the Treatment Study. If you feel there has been an error, please contact the study team (by clicking here) or calling (416) 323-6400 x5125 or x2749.

By completing this section of the form, you are consenting to allow the study team to contact you and your secondary contact (if needed) for study-related questions or issues.

First Name:

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Last Name:

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Home Telephone Number:

Cell Telephone Number:

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Work/Other Telephone Number:

Email Address:

* must provide value

Please note, e-mail messages are not encrypted, may exist indefinitely, and Women's College Hospital cannot guarantee the security of messages sent outside the hospital email system (for example, to a Hotmail or Gmail account).

I consent to email correspondence with the study team.

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Yes No

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Mailing Address:

Street:

Municipality (City/Town):

Province/State:

Country:

Postal Code:

In the case that we are unable to reach you at the above number(s), please provide contact information for an alternate contact we may contact:

Full Name:

Relationship:

Alternate Contact Email:

Alternate Contact Phone Number:

How would you prefer to complete the study consent forms?

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REDCap (You can complete your consent form on our secure research database, REDCap. Once you complete this form you will be directed to the consent form)

Email (The study team will send PDF copies of the study forms to your email you specified above)

Mail (The study team will mail hard copies of the study forms to the address you specified above)

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How would you prefer to receive study questionnaires:

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REDCap / Email (Links to online versions of study questionnaires will be sent to the email address provided above via REDCap)

Mail (Paper copies of study questionnaires will be mailed to the address provided above)

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Comments on contact preference

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How did you hear about our study?

Please select one of the following options:

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Women's College Hospital website

Google Search

Facebook Group

Love Research Army

FORCE

ICARE (Inherited Cancer Registry)

Other

Prefer not to answer

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Are you participating in other research studies?

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I am not participating in any other research studies

ICARE (Inherited Cancer Registry)

Other

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We partner with ICARE for this study. Please enter your ICARE ID so we can prevent duplication of data:

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If there is anything else we should know please let us know here:

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