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YjfsnB8agCYzNuajFuF4xLFUHjbraHgXgPqWCiDG89JHcEuyRjvdRpYi5Jsg7QN3Na2MDiJZQC4i2cCmG5DRv58d6XG27ErqWYHnHntgxKYwrrgqs5waz6h8xb9L

Participant Information

Hello!

Thank you for your interest in participating in our INHERIT Study. Please fill out the survey below.

**Please note, at this time, the INHERIT Study is only open to those who currently reside in the United States. We are hoping to expand to other areas in the future; please check back periodically for these updates.

Thank you very much,
The INHERIT Study Team

The option "" can only be selected by itself. Selecting this option will clear your previous selections for this checkbox field. Are you sure?

First Name:

Last Name:

Date of Birth:

Email Address:

Phone Number:

Address:

Address Line Two:

City:

State:

Zip Code:

Please select the time zone you are currently located in:

Do you currently have or have you ever had lung cancer?

* must provide value

Yes

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Do you or a family member carry a germline (inherited) EGFR mutation?

* must provide value

Yes

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Which particular EGFR mutation do you or your family member carry?

* must provide value

EGFR T790M

Other:

I don't know

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Have you ever had a CT Scan of the chest?

* must provide value

Yes

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Where was your most recent chest CT Scan?

* must provide value

When was your most recent chest CT Scan?

* must provide value

Were lung nodules found on your chest CT Scan?

* must provide value

Yes

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Would you be interested in participating in CT Chest screening as part of this study? (With costs of scans paid for by the INHERIT Study.)

* must provide value

Yes

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Would you be willing to travel to Dana-Farber Cancer Institute for this scan?

* must provide value

Yes

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Do you or a family member carry germline mutations in any of the genes listed below?

* must provide value

ATM

BRCA1

BRCA2

CHEK2

HER2 (also known as ERBB2)

PTEN

RAD51 (RAD511C, RAD51D)

TP53 (also known as P53)

YAP1

Other: (Please Specify)

None of these apply

Unknown

Do any of the following apply to you or your family?

* must provide value

More than one first-degree family member (e.g. two or more of the following: brother, sister, mother, father, or child) with lung cancer.

Family members with lung cancer in more than one generation (e.g., lung cancer in grandmother and mother).

More than one primary lung cancer diagnosis in your lifetime.

None of the above.

Date survey was completed:

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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.