Cancer Survey

This poll is for inhabitants and residents of the Terry Park CommUNITY in Huntington Beach, it is for research purposes only.
The Cancer Registry of Greater California and the California Public Health Institute is looking into a potential Cancer Cluster in and around Terry Park
Please help us gather information by filling out the information below. Only use your initials not full name.

Cancer Poll for Terry Park CommUNITY, data gathering for CRGC

Your Initials*

E-mail*

Have you or any of your current household been diagnosed with any type of cancer in the last 25 years?

Yes
No
Yes, but before living in this housing tract
Yes, after we started living here

Have any of your family or friends that lived near Terry Park been diagnosed with cancer and moved away?

Yes
No
Yes, but is deceased

Date of Diagnosis*

Date of Diagnosis

Cancer Type(s)

Carcinomas
Breast
Lung
Prostate
Colorectal
Sarcomas
Leukemia
Central Nervous System Cancer
Lymphoma and Myeloma
Blastomas
Other

Relationship to you: Self, Spouse, Parent, Child, Animal*

Age Range of person*

What specific concerns or ideas do you have about the local environment do you have?

Air
Water
Soil
Food
Housing
Other

How long living near Terry Park?*

Tell us more without HIPPA violations

Terry Park CommUNITY

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