Data Form

Thank you for your interest in our study! Please complete the following screening form to help us determine your eligibility for our study

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Please identify yourself:

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Adult cancer survivor (20+ years old)

Adolescent cancer survivor (14-19 years old)

Child cancer survivor (7-13 years old)

Parent/guardian of a childhood and adolescent cancer survivor

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The research team at the BC Children's Hospital, PHSA studying Educational Outcomes in Childhood and Adolescent Neuro-oncology Survivors would like to ask you confidential questions in this survey to assess your eligibility for our research study. The goal of the research is to gain insight into the educational needs, challenges, and successes of childhood cancer survivors as they navigate their academic journeys. Your survey responses will assist us in determining your eligibility for participation and ensure comparable group characteristics for analysis. If you meet our study criteria, we will contact you to review the main study consent form and schedule the interview session.

If you do the survey, you are consenting (agreeing) to participate. Completion of the survey is voluntary. Children under the age of 19 who are not legally competent to consent on their own behalf, should be accompanied by a parent or legal guardian when completing this survey.

It will take no more than 10 minutes to complete the survey. The deadline to complete this survey is April 30, 2025.

We are asking you to share the following personal information:
1. Age
2. Diagnosis and treatment information
3. Post treatment effects
4. Your personal email address

* We would like to use your email address to communicate with you about this research study. Please note that some email services (e.g. Gmail, etc.) may store email contents, including personal information like your name and health information, outside of Canada, where privacy and security standards may be different. If you ever want to stop communicating by email or have any questions about this topic, please contact the project manager, Sara Izadi-Najafabadi at sizadi@bccrc.ca

Only the study team and the technical support team at the PHSA will access your information. The results of this survey are confidential. When results are reported, presented, or published the project team will remove any information that could identify you or anyone else. The team may use a quote from your comments if provided. Survey data will be stored securely at the BCCRI, PHSA for a minimum of 5 years after completion of the study. Collected data will be disposed in accordance with PHSA IMITS standards.

Your personal information is protected by our privacy law in BC. This law is called the Freedom of Information and Protection of Privacy Act (FIPPA). We are collecting your information under section 26 (e ) of FIPPA.

If you have questions about the survey or your information please contact: Sara Izadi-Najafabadi; address: 2nd floor, 675 W 10th Ave., Vancouver, BC, V5Z 1L3; phone number: 604-675-8065

If you have any concerns or complaints about your rights as a research participant, and/or your experiences while participating in this study, or if you have any privacy related complaints, contact the Research Participant Complaint Line in the University of British Columbia Office of Research Ethics by e-mail at RSIL@ors.ubc.ca or by phone at 604-822-8598 (Toll Free: 1-877-822-8598). Please reference the study number (H24-00682) when contacting the Complaint Line so the staff can better assist you.

I have read and understand this form. I voluntarily consent to the survey conducted by the Education Outcomes in Childhood and Adolescent Neuro-oncology Survivors research team at the BCCH, PHSA collecting, using, and disclosing the information I provide.

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Yes, I consent/assent if under the age of 19

I do not consent/do not assent if under the age of 19

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Please type in your full name (first and last name) to provide consent/assent.

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Parent or Legal Guardian: Please provide consent for your child (under 19 years old) to complete this survey by typing your first and last name.

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Please provide your Email address

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.