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 North American 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:

nCGAZj4XMBWZ2QH6U9DrH8tPuZLRnXQPZLNxQREN5f3DHs

UCSF HDFCCC Office of Community Engagement's Request Portal

Thank you for your interest in connecting with our office. Please include as much detail as possible in your request. If you have multiple requests, please fill out a SEPARATE form for each request. This prevents requests from being overlooked and ensures that your request reaches the right staff member as quickly as possible.

Request Processing Time:

Material requests must be made at least 7-10 days in advance
OCE consultation (e.g. letters of support, grant collaboration), cancer education, and sponsorship requests must be made at least 1 month in advance

Important:

Please make sure to press the SUBMIT button after completing the form. If you do not receive a confirmation email after submitting your request, you may not have pressed submit or there was a typo in your contact email. Please email hdfcccoce@ucsf.edu if you do not receive a confirmation email.

1. Today's date

* must provide value

M-D-Y

2. Your first and last name

* must provide value

3. Organization or affiliation (If none, write N/A)

* must provide value

3a. Organization zip code (if not part of an organization, please provide your zip code)

* must provide value

4. Your email

* must provide value

5. Your contact phone number

6. Is there an alternate contact person for this request?

* must provide value

Yes

reset

Contact name

* must provide value

Contact email

* must provide value

Contact phone number

7. What is your request for?

If you have multiple requests, please fill out a SEPARATE form for each request. This prevents requests from being overlooked and ensures that your request reaches the right staff member as quickly as possible.

* must provide value

consultation with OCE Director - Dr. Nynikka Palmer (e.g., letter of support, grant collaboration)

consultation with the HDFCCC Community Advisory Board (CAB)

cancer education services (e.g., speaker, tabling, inflatable exhibit, virtual presentations)

cancer education materials (e.g., brochures or push cards)

event sponsorship

volunteer with the OCE

grant portal access

other

reset

Please continue to the next page to let us know a little bit more about the event or activity where you plan to distribute the materials.

8. How can Dr. Palmer help support you?

* must provide value

Letter of support from OCE for upcoming proposal

Collaboration with OCE on grant proposal (including engagement with community partners)

Collaboration on funded grant

Community engagement opportunity

Research/project consultation

Mentorship

Assistance with community engagement/partnership (e.g., establish partnership, recruitment)

Other

reset

Please provide more details.

* must provide value

Expand

8. Is there a cost for us to participate in your event or activity?

We prioritize attending events where our participation is free

* must provide value

Yes

reset

Please specify the cost.

9. Are you requesting in-person or virtual cancer education services?

* must provide value

In-person

Virtual

reset

10. What in-person cancer education services are you requesting? (please select all that apply)

* must provide value

Cancer education speaker

Cancer information dissemination (i.e. tabling)

Cancer education with the inflatable colon, lung or pink ribbon

10. What virtual cancer education services are you requesting? (please select all that apply)

* must provide value

Cancer education speaker

Cancer education games (e.g. cancer education Bingo, scavenger hunt and discussion)

Watch party - view a presentation and discuss

11. Which inflatable are you requesting? We can only bring out one inflatable at a time.

Colon: 100 pounds, inflated size: 12 feet high, 12 feet wide (right to left), 10 feet deep (front to back)

Lungs: 60 pounds, inflated size: 14 feet high, 14 feet wide (right to left),11.5 feet deep (front to back)

Pink Ribbon (Breast Cancer Awareness): 5 pounds, inflated size: 5 feet high by 3 feet wide

All require electricity or a battery-powered generator to keep inflated.

* must provide value

Colon

Lung

Pink Ribbon

reset

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.