Awareness Questionnaire Tell us how we can help, please share your experience with BNRAC. Thank you! Name* First Last Email* Phone*Do you know someone who has been affected by Cancer?*YesNoHave you been directly affected by Cancer?*YesNoHas your family been impacted by a close friend/family member fighting against the challenges of Cancer?*YesNoOf the choices below, check the box that indicates areas of challenges for you or your love one* Select All Emotional Support Service Family Support Services Driving Loss of Hair Paying a Utility Bill Cooking a Simple Meal Trying to get to an Appointment Transportation Services Other Please ExplainEmotional Support Service - On the choice selected, Please rank the biggest struggle you face (directly or indirectly). You can select on a scale between 0 - 5 with 0 = no impact to 5 = Extremely Impactful.*012345Family Support Services - On the choice selected, Please rank the biggest struggle you face (directly or indirectly). You can select on a scale between 0 - 5 with 0 = no impact to 5 = Extremely Impactful.*012345Driving - On the choice selected, Please rank the biggest struggle you face (directly or indirectly). You can select on a scale between 0 - 5 with 0 = no impact to 5 = Extremely Impactful.*012345Loss of Hair - On the choice selected, Please rank the biggest struggle you face (directly or indirectly). You can select on a scale between 0 - 5 with 0 = no impact to 5 = Extremely Impactful.*012345Paying a Utility Bill - On the choice selected, Please rank the biggest struggle you face (directly or indirectly). You can select on a scale between 0 - 5 with 0 = no impact to 5 = Extremely Impactful.*012345Cooking a Simple Meal - On the choice selected, Please rank the biggest struggle you face (directly or indirectly). You can select on a scale between 0 - 5 with 0 = no impact to 5 = Extremely Impactful.*012345Trying to get to my Appointments - On the choice selected, Please rank the biggest struggle you face (directly or indirectly). You can select on a scale between 0 - 5 with 0 = no impact to 5 = Extremely Impactful.*012345Transportation Services - On the choice selected, Please rank the biggest struggle you face (directly or indirectly). You can select on a scale between 0 - 5 with 0 = no impact to 5 = Extremely Impactful.*012345Other - On the choice selected, Please rank the biggest struggle you face (directly or indirectly). You can select on a scale between 0 - 5 with 0 = no impact to 5 = Extremely Impactful.*012345PhoneThis field is for validation purposes and should be left unchanged.