The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Z7GnzMxzgRuQdMtZbSoIEB6geICG9eQ4LNyqaJ24jFmgGX8zQucTVrvuboQMAzde93SmG6QhJ7i8CmijCvf37ZTLsmNXcpmVZNPMuAx45wHZZzs2XE5HCGgB6NpYL8

OCOE Education & Outreach Intake Form

Welcome to the Office of Community Outreach and Engagement's (OCOE) Education & Outreach Intake form!

If you would like have the OCOE present at your event, request cancer education, request a speaker, or anything else, please fill out the following form. Once submitted, the OCOE staff will review your request and approve based upon availability.

These are your following options to choose from:

Event Request: If you have a health fair, symposium, or any large gatherings where you are wanting to promote cancer/health related education and you would like the OCOE's presence there--with CECE :)
- Please note, we will be happy to showcase CECE if it's a health related event towards health awareness.

Health Education: If you need cancer or cancer-related education material recommendations that you would like to hand out for your audience.
- If you are looking for a more tailored cancer search for personal concerns, please visit the National Cancer Institute's Cancer Information Service online at www.cancer.gov or via telephone 1-800-4-CANCER

Speaker Request: If you would like a content expert come present on a specific topic for your audience.

Letter of Support: If you are requesting a letter of support from the OCOE that supports your study or grant proposal. Must be geared towards a sense of community involvement.

Other: Any other request that you are wanting from the OCOE but not shown in the above options.

Note: If you are part of a research team that is interested in technical assistance or support with recruitment and retention for a study, please use the OCOE Recruitment & Retention Intake Form at https://redcap.link/ocoe_rrr.

Thank you for your interest in our program for your event needs.

-The OCOE Staff

Name:

* must provide value

Name of Organization:

* must provide value

Request Type:

* must provide value

Date of Event:

* must provide value

M-D-Y

Event Name:

* must provide value

Duration of Event (Start to End) :

* must provide value

Organization's Person of Contact:

* must provide value

Contact's Email:

* must provide value

Contact's Telephone #:

* must provide value

Event Address:

* must provide value

Expand

What specific topic you would like one of our Community Health Educators to speak on?

* must provide value

Expand

How long would you like the presenter speak for?

* must provide value

Expand

How would you like the presentation to be given?

* must provide value

Power Point

Flip Charts

Small Group Discussion or Talking Circle

Other

reset

If other, please specify:

* must provide value

Expand

Please specify which racial/ethnic population you are/will be working with on your project (Check all that apply):

* must provide value

African American/African Descent

White/Caucasian

Indigenous (American Indian/Alaska Native)

Pacific Islander/Native Hawaiian

Asian

Hispanic/Latinx

Not listed, please specify

If not listed, please specify which racial/ethnic population you are/will be working with on your project:

* must provide value

Expand

Please specify any intentional intersectionality that you are seeking in the population that you would like to work with (Check all that apply):

* must provide value

LGBTQIA+

Immigrant

Refugee

People with a physical disability

People with a mental disability

Populations in an underserved community (lack of access to education, lower socio-economic status, etc.)

Not listed

None

If not listed, please specify here any other intentional intersectionality that you are seeking in the population that you would like to work with:

* must provide value

Expand

Cancer Focus Area (check all that apply):

* must provide value

Breast

Prostate

Lung

Colon

Cervical

Other

If other, please specify here:

* must provide value

Expand

Would you like CECE, the Inflatable Colon, present at the event?

Yes

reset

Please select one of the following the cancer information relates to (check all that apply):

* must provide value

General Cancer Overview (includes all options below)

Cancer Prevention

Cancer Screening

Cancer Diagnosis and Treatment

Cancer Support

If you are requesting a letter of support, please provide a description of it's purpose and objective:

* must provide value

Expand

Please upload a copy of a template you would like us to use:

Upload file

When would you like this information/item by? (Please allow 4-5 business days to prepare item(s) for you.)

* must provide value

M-D-Y

Please specify what you are requesting from the OCOE?

* must provide value

Expand

Other comments you would like to mention or add?

Expand

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.