Are you a cancer survivor who had limitations in activities of daily living prior to your cancer?

I invite you to participate in a study to help us understand how cancer survivors who had a functional limitation or disability prior to being diagnosed with cancer take care of their health. You can earn up to $ 25 by completing a questionnaire packet.  If you are over the age of 21, and interested in participating in this study, please complete the information requested on this page, fold it so the envelope on the back is showing, and mail it back to me. You can also fax it to 512-475-8755

or call 1-800-687-8010 (free), 512-232-3492. You must have completed active treatment to participate.

Heather Becker, Ph.D.

The University of Texas at Austin

School of Nursing

heatherbecker@mail.utexas.edu

What is your cancer diagnosis? ______________________________

Have you completed active treatment?      ____ yes        ____ no

Are you limited in any way in any activities because of physical, mental, or emotional problems?     ____ yes            ____ no

Did this functional limitation exist PRIOR to your cancer diagnosis?

                                                ____ yes        ____ no

Name______________________________ Email____________________

Address____________________________________________________

City/State/Zip_______________________________________________

Phone ________________________      Date of Birth ____/____/_______