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Cancer Cientouno Registration Form

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Cancer CientoUno (101) Informed Consent
This online training program is being offered by the U54 Ponce Health Sciences University-Moffitt Cancer Center (PHSU-MCC) Partnership Outreach Core (led by Dr. Shannon Christy and Dr. Julio Jiménez). The purpose of this online Cancer CientoUno program is to train community members on how to deliver cancer education in Spanish to members of their local communities. Because data are being collected as part of this online training program, it is considered a research study. As a participant in the Cancer CientoUno online program, you will be asked to complete a registration form and 11 educational modules at your own pace. At the end of each module, you will be asked to complete a brief evaluation survey. In addition, you will be asked to complete a mid-program evaluation survey and a 6-month follow-up evaluation survey. Your responses will remain confidential. Only study team members and partners will have access to the information you share with us. Your responses to the registration form will help us understand who has participated in the program, and the module evaluations and 6-month follow-up surveys will help us assess this training program, refine its content and learning objectives, and tailor the information to meet your educational needs. The study team may choose to publish findings from this study to advance research in cancer education training, but published data will not contain information that could identify you. The Cancer CientoUno website may use data collection technology such as Google Analytics and cookies to collect and store personal information when you use the website. Information that may be collected includes pages visited, browser type, device type, domain and operating system information, IP address, system language, country and time zone, and the times you visit our website. Therefore, by using this website, you acknowledge that such information may be collected from you. Please review our Privacy Policy and Terms & Conditions statement for more information. The U54 PHSU-MCC Partnership has taken reasonable steps to ensure the security of your personal information. The project website and database will be protected and accessed only by authorized individuals, including research team members and partners. Participant data will be stored on password-protected computers that are backed up daily to a secure server. Your participation in this online training program is voluntary, and you may choose not to complete this training at any time. You may also choose not to answer specific questions in the surveys mentioned above. By participating in this online training program and its surveys, you agree to take part in this research study. If you have any questions, please contact Dr. Shannon Christy at shannon.christy@moffitt.org.
Section I: Eligibility requirements
Thank you for your interest in the Cancer CientoUno program! As a requirement to complete this training program, you must training program, you must confirm your ability to speak, read and write Spanish.
Can you speak Spanish?*
- Yes, fluid
- Yes, conversational
- No
Unfortunately, you cannot participate in our program at this time unless you speak, read, or write Spanish fluently. You can contact us through the email address at the top of this page with any questions or concerns.
Can you read Spanish?*
- Yes, fluent
- Yes, intermediate
- No
Unfortunately, you cannot participate in our program at this time unless you speak, read, or write Spanish fluently. You can contact us through the email address at the top of this page with any questions or concerns.”
Can you write Spanish?*
- Yes, fluent
- Yes, intermediate
- No
Unfortunately, you cannot participate in our program at this time unless you speak, read, or write Spanish fluently. You can contact us through the email address at the top of this page with any questions or concerns.”
Do you have access to a computer/electronic device and internet service?*
- Yes
- No
Unfortunately, you need to have access to a computer or tablet with internet service to participate in our program at this time. You can contact us via the email address at the top of this page with any questions or concerns.
Would you be able to complete 11 modules in approximately 15 weeks?
- Yes
- No
While you are not required to complete the program in approximately 15 weeks, you are strongly encouraged to do so. You can contact us via the email address at the top of this page with any questions or concerns.
Section II: Socio-demographic Information
We ask that you complete this registration form to help our research team better understand who completes this training program and to evaluate how the information learned is used. We will keep the information you provide on this form confidential. We request contact information to send the certificate of completion. training program, you must confirm your ability to speak, read and write Spanish.
Please provide your name as you would like it to appear on your course completion certificate.
Name*
First Middle Last
Phone*
Email*
Enter Email Confirm Email
Preferred Mailing Address*
Street Address City State ZIP Code
Age (in years)*
Are you currently a student?*
- Yes
- No
Name of institution:
What is your current specialization/concentration?
Current level of education/classification:
- First year of university (Freshman)
- Second year of university (Sophomore)
- Third year of university (Junior)
- Fourth year of university (Senior)
- Masters
- Doctorate
What is the highest level of education you completed?
- Never went to school
- Elementary school (grades K-5)
- Middle School (grades 6-8)
- Some secondary school
- High school graduate/GED or equivalent
- A university or technical school
- Associate’s degree
- Bachelor’s degree or diploma (e.g., BA, AB, BS, BBA)
- Master’s degree (e.g., MA, MS, MEng, MEd, MBA)
- Professional School Degree / Doctorate
Are you currently employed as any of the following?*
Check all that apply
- Community Health Worker
- Health promoter
- Patient Navigator
- Health Educator
- Nurse
- Social worker
- Medical Assistant/Physician Assistant
- Other Occupation
- Not Applicable
Please indicate your job title:
Sharing your socio-demographic information will help us better understand who has completed the Cancer CientoUno program. If a summary of the sociodemographic characteristics of program participants will be created, identifying information (e.g., names and contact information) will not be included.
Do you consider yourself Hispanic or Latino/ Latina?*
- Yes
- No
- I prefer not to answer
What is your race ?*
Check all that apply:
- White
- Asian
- American Indian or Alaska Native
- Black or African American
- Native Hawaiian/ Pacific Islander
- More than one race
- None of these options/Other
- I prefer not to answer
If you answered “More than one race” Please specify:
If you answered “None of these options/Other” Please specify:
What is your gender?*
Check all that apply
- Cis-gender Woman (female sex assigned at birth and identify as woman)
- Cis-gender Man (male sex assigned at birth and identify as man)
- Transgender Woman
- Transgender Man
- Non-binary gender
- Gender queer
- Agender
- Gender fluid
- I identify myself as
- Prefer not to answer
I identify myself as:
How did you hear about this program?*
Check all that apply
- Community Event
- Webinar
- Facebook
- Someone who had taken the course
- For my work
- Conference/Symposium
- Friend
- Listserv
- Other
Please specify:

On a scale of 1 to 5, what is your degree of knowledge of the following topics?*

	No knowledge (1)	Little knowledge (2)	Neither too much nor too little knowledge (neutral) (3)	A lot of knowledge (4)	Subject Matter Expert (5)
Cancer prevention:
Early detection tests for cancer:
Cancer diagnostic tests:
Cancer treatment:
Cancer survivorship:

Please describe a personal objective you hope to achieve by participating in this training program:*
1000 characters or less
Please describe a professional objective you hope to achieve by participating in this training program:*
1000 characters or less
Session III: Ways of providing education
Do you currently provide cancer-related education or support to communities? (If yes, explain and include the specific cancer topics you address).*
- Yes
- No
If yes, provide*
1000 characters or less
In what environment do you intend to provide the information you will learn in the Cancer CientoUno program?*
Check all that apply
- Clinic
- Community
- Classroom
- Individual (one at a time)
- Institution
Please indicate the name of the institution and the city(s) and state(s)/U.S. territory(ies) in which you intend to provide the information you learn in the CientoUno Hundred and One program.
Institution Name:

City(s):

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State(s):

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U.S. Territory(ies):

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To which groups or audiences do you plan to give the information you will learn in the Cancer CientoUno program?

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Group or audience
By participating in the Cancer CientoUno training program, you agree to be contacted so that the program administrators can know how you have used the information presented in Cancer CientoUno.*
- Yes
- No
Please indicate your preferred method for us to contact you.
- Phone
- Email
Optional Phone
By phone- Enter a phone number if you want us to use a different number than the one you are using to register.
Optional Email Address
By Email – Enter an email address if you wish to use a different email address than the one you are using to register.
Section IV: Create user name and password
Por favor crea su nombre de usuario y contraseña
User name*
Password*
Enter Password Confirm Password

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Cancer Cientouno Registration Form

Cancer CientoUno (101) Informed Consent

Section I: Eligibility requirements

Section II: Socio-demographic Information

Session III: Ways of providing education

Section IV: Create user name and password

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