Bladder Cancer Support Group Webpage Listing Survey

1.What is the name of the Support Group that you are submitting?

2.If the name of the support group changed in the past year, please provide previous name. If not, please skip to the next question.

4.When does the support group meet? (Example: 1st Tuesday of the month at 7:00 PM ET)

Month:

Week:

Day:

Time of day:

Time zone (required):

5.Are the support group meetings in person, virtual, or hybrid?

In person only

Virtual only

Hybrid (meets virtually and in person)

Other (please specify)

6.Do you require participants to register for the support group?

Yes

7.Please provide registration/log in information:

8.For in person meetings, please provide the location where the support group meets:

Institution/Building name

Street address

Room number/name (if available)

City

State

Zip code

Parking Information

9.Is the support group sponsored/hosted by an organization?

Yes, support group is hosted/sponsored by an organization

No, support group is sponsored by a patient volunteer

Other (please specify)

10.Please provide the name of the sponsoring organization:

Hospital/Cancer Center:

Medical Practice:

Non profit:

Other (please specify):

11.Who is the main point of contact for the support group?

Name:

Credentials (i.e. nurse, social worker, patient/survivor, etc):

Phone number:

Email address:

12.Second point of contact for the support group, if available:

Name:

Credentials (i.e. nurse, social worker, etc):

Phone number:

Email address:

13.Please provide a brief description of your support group:

14.Contact information for the person completing this entry: (For internal use only)

Name:

E-mail:

15.If there anything else that you would like us to know about your group? (For internal use only)

Thank you for helping us provide the most current listing of community and virtual support groups for bladder cancer patients.