Cimavax

Are you calling for yourself, or on behalf of someone else? * For myself For someone else

Your relationship to the patient *

Patient's first name *

Patient's last name *

Your Patient's Email Address *

Patient's Phone * (###-###-####)

What is the best method to contact you the patient? * Phone call Email

May we identify ourselves over the phone or in a voice message? *

* In order to protect your personal health information, if we call you and someone else answers the phone, or the call goes to your voicemail, we will not identify ourselves as calling from Roswell Park Comprehensive Cancer Center, unless you give us permission in advance to do that.

What is your the patient's preferred language (e.g., English, Spanish, Mandarin, etc.)? *

Are you Is the patient at least 18 years old? *

Yes No

We are sorry. Based on this selection, you are not eligible for this study.

Are you Is the patient able to travel to Buffalo, New York, every week until treatment is completed? *

Yes No

We are sorry. Based on this selection, you are not eligible for this study.

Which campus would you the patient prefer to be treated at? *

Main Campus (Downtown Buffalo) Amherst Campus No Preference

Do you Does the patient have active cancer? *

Yes No

The CIMAvax study for those with lung cancer is no longer accepting patients. To find other clinical trials at Roswell Park that may be appropriate for your type of cancer, please visit https://www.RoswellPark.org/clinical-trials.

Are you Is the patient between the ages of 50 and 79? *

Yes No

We are sorry. Based on this selection, you are not eligible for this study.

Have you Has the patient ever been diagnosed with cancer? *

Yes No

Was your cancer Was the patient's cancer diagnosed between stages 1A and 3A? *

Yes No

We are sorry. Based on this selection, you are not eligible for this study.

If you If the patient had surgery and completed chemotherapy for your the patient's past diagnosis, was it more than three months ago? *

Yes No N/A

We are sorry. Based on this selection, you are not eligible for this study.

Do you Does the patient have any risk factors?

COPD

A first-degree relative with lung cancer

A history of pneumonia within the past 5 years

Occupational exposure to asbestos or radon

None of the above

Are you Is the patient a current smoker, or have you has the patient smoked within the past fifteen years? *

Yes No

We are sorry. Based on this selection, you are not eligible for this study.

Where did you the patient hear about the CIMAvax Trial?

Finally, which of the following factored into your the patient's decision to apply for this trial?

Please note: Your answers for this question are simply used for research purposes and will not be a factor in your eligibility.

I like drugs that activate my immune system.
I think this vaccine will make other drugs work better.
I am interested in any trial I qualify for that might extend my life.
I think vaccines cause fewer side effects compared with standard cancer therapy.
I think research is important.

Your Patient's Residential Address