Cancer Education Materials Request

Name *

First Name

Last Name

Address *

Location of facility where materials will be used.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Which population/s do you anticipate will be viewing/handling the booklets in your setting? *

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Medical Staff

Social Workers

Patients

Caregivers

Other

How would you describe yourself? *

Student

Healthcare Professional

Government Staff

NGO Staff

Patient

Other

Which language/s are you interested in downloading? *

Select All

Acholi/Luo (Uganda)

Arabic

Chichewa (Malawi)

Chinese (Simplified)

Chinese (Traditional)

English

Haitian Creole

Hausa (Nigeria)

Igbo (Nigeria)

Kinyarwanda (Rwanda)

Kiswahili (Kenya)

Luganda (Uganda)

Ndebele (Zimbabwe)

Pidgin English (Nigeria)

Portuguese

Rukiga (Uganda)

Setswana (Bostwana)

Shona (Zimbabwe)

Spanish

Yoruba (Nigeria)

I agree to receive a brief quarterly questionnaire asking for basic information about usage of the CEM booklets. *

This information will help GO plan for expansion of this work.

Yes

No