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Lupus Buddy Program Survey Form
The Lupus Buddy Program is an initiative of the Lupus Foundation of Northern California. More information can be found on LFNC.org. LFNC treats personal and medical information with strict confidentiality and reserves the right to share this information internally and with its Buddy Program managers and coordinators who follow the same strict policy.
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Full Name
*
Your answer
Phone:
*
Your answer
Email:
*
Your answer
Street Address
*
Your answer
City, State, Zip
Your answer
Gender
*
Male
Female
Age (in years)
*
Your answer
Date Diagnosed with lupus
*
(please enter '1' for day if you do not remember the exact date - month and year are sufficient)
MM
/
DD
/
YYYY
Type of Lupus You Have
*
such as SLE, nephritis, etc.
Your answer
Do you consider yourself (please choose one)
*
A patient with a great deal of experience and knowledge about lupus
A patient who is beginning to learn about lupus
Other:
Are you Interested at this time in this program?
Yes
No
Clear selection
What is the one thing you would most want out of the Buddy Program?
Your answer
How much time per month (in hours) would you be willing to invest in this program?
Your answer
Do you have any concerns about this program?
We would like to reiterate that strict confidentiality governs all data sharing within this program.
Your answer
Would you like to be a mentor, a mentee, or a buddy?
Mentor
Mentee
Buddy
Not sure - please assign me!
What mode of contact would prefer with a potential match?
Check all that apply. For all types of contact, the participant is responsible for expenses that may be incurred (e.g. gas to drive, texting or internet charges, etc.)
Phone (Voice)
Email
Texting (phone numbers will be shared)
Video chat
In-person
May we share the information you have given us, as appropriate, with your potential match?
*
Yes
No
What is the one thing you have most to offer to this program?
Your answer
What is the one thing you hope most to learn from this program?
Your answer
Would you like to volunteer your time to administer this prorgam?
Yes
No
Clear selection
Are you interested in this program at this time?
*
Yes
No
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