Apply to ÁRBOLES – Programa de ÁRBOLES

If you are interested in applying to the ARBOLES Familiares Training Program, start today in your preferred language! The application does not have to be completed in one sitting, if you would like to save your application and return to it at a later time you may do so by clicking the Click and Save button located on the bottom left hand side of the application. You will be able to complete this form from your computer, tablet, or phone.

Step 1 of 11 - Participation Requirements

Section 1: Participation Requirements
Which of these trainings will you be available to attend? (Please check all that apply)*
Acceptance into a specific training will be based on eligibility and the number and geographic location of applicants. To increase your chances of being accepted, please select all training options that work for your schedule.
- Spring 2020- Monterrey, CA March 25-27, 2020
- Fall 2020- East Coast- Dates and Location TBD
- Future Trainings
Thank you for your interest in participating.
Unfortunately, we are only able to accept applications from candidates who can attend the workshop and complete the online modules. If you would like to be considered for future training sessions or would like to provide more information to the training team, please email arboles@georgetown.edu or call (877) 201-4703
Do you have access to a computer and internet service?*
- Yes
- No
Thank you for your interest in participating.
Unfortunately, we are only able to accept applications from candidates who can attend the workshop and complete the online modules. If you would like to be considered for future training sessions or would like to provide more information to the training team, please email arboles@georgetown.edu or call (877) 201-4703
Would you be able to complete 8 one hour online learning sessions over a 4-month period?*
- Yes
- No
Thank you for your interest in participating.
Unfortunately, we are only able to accept applications from candidates who can attend the workshop and complete the online modules. If you would like to be considered for future training sessions or would like to provide more information to the training team, please email arboles@georgetown.edu or call (877) 201-4703
Would you be able to complete a 6-month and a 12-month follow up survey online?*
- Yes
- No
Thank you for your interest in participating.
Unfortunately, we are only able to accept applications from candidates who can attend the workshop and complete the online modules. If you would like to be considered for future training sessions or would like to provide more information to the training team, please email arboles@georgetown.edu or call (877) 201-4703
Are you currently employed or volunteer with a clinic, hospital or agency that provides services to Latinos?*
- Yes, currently employed
- Yes, currently volunteer
- No
- Please include two professional references from your organization who can testify about your role as a volunteer
  Reference One
- Name
  First Last
- Organization
- Relationship
- Phone Number
- Reference Two
- Name
  First Last
- Organization
- Relationship
- Phone Number
Thank you for your interest in participating.
Unfortunately, we are only able to accept applications from candidates who can attend the workshop and complete the online modules. If you would like to be considered for future training sessions or would like to provide more information to the training team, please email arboles@georgetown.edu or call (877) 201-4703

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Section 2: Background Information
Applicant's Name*
First Middle Last
Date of Birth*
MM
DD
YYYY
Age*
Mailing Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Email*
Secondary Email
Your Telephone Number*
Cellphone:
What is the best way to reach you? :*
- Telephone
- Email
May we leave a voicemail?*
- Yes
- No
Are text messages okay?*
- Yes
- No
Where or in which country were you born?*
Specify which country:*
How many years have you lived in the United States?*
Ethnicity:*
- Hispanic/ Latino
- Not Hispanic or Latino
Sex:*
- Female
- Male
Race: (Check all that apply)*
- American Indian or Alaska Native
- Black or African American
- White
- Asian
- Native Hawaiian/Pacific Islander
- More than one race
- Prefer not to respond
- Other
Other Race:*
Workplace:*
How many years have you been working in your profession?*
Which of the following best describes your job title?*
(Check all that apply)
- Community Health Educator
- Lay Health Worker
- Promotor/ Promotora
- Patient Navigator
- Other
Other Job Titles*
Add additional items by clicking the + button.
What are your primary job responsibilities?*
Check all that apply
- Patient education
- Patient navigation
- Community education
- Community outreach
- Training of other colleagues
- Other
Other job responsibilities:*
Add additional items by clicking the + button.

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Section 3: Educational Background
Please list your education in chronological order starting with the most recent first.
- Institution and Location:*
- Degree / Certification (If Applicable):*
- Dates Attended:*
  From:
- *
  To:
- Field of Study:*
- Institution and Location:
- Degree/ Certification (If Applicable):
- Dates Attended:
  From:
- To:
- Field of Study:
- Institution and Location:
- Degree/ Certification (If Applicable):
- Dates Attended:
  From:
- To:
- Field of Study:
- Institution and Location:
- Degree/ Certification (If Applicable):
- Dates Attended:
  From:
- To:
- Field of Study:
Health Educator:*
Licensures or Certifications (Check any that apply)
- CHES
- MCHES
- CCHW
- Other
- None
List other certification(s)*
Add additional items by clicking the + button.
Promotor/ Promotora:*
Licensures or Certifications (Check any that apply)
- CCHW
- Other
- None
List other Licensures or Certifications*
Add additional items by clicking the + button.

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Section 4: Workplace Setting
1. Which of the following best describes your workplace or volunteer place?*
- University Hospital
- Community Hospital
- Public Health Community Organization
- Health Department
- Community-based organization
- Cancer Center
2. Does your workplace (volunteer place) have a way to identify patients at increased risk for hereditary cancer (e.g., cancer that runs in families)?*
- No
- Not Sure
- Yes
If yes, please indicate who identifies these patients:*
- Staff member
- Local genetic Counselor
- Local doctor

3. Please indicate if these services for hereditary breast and ovarian cancers (HBOC) are available or not at your workplace (volunteer place)*

	Yes	No	Not Sure
Established Genetic Risk Assessment of Hereditary Breast and Ovarian Cancer referral guidelines/ procedures
Genetic counselor(s), clinical geneticist(s), on staff
Medical Oncologist on staff
Partnership/ contract with genetic counselor(s), clinical geneticist(s), and genetic testing laboratories
Partnership / contract with medical oncologist(s)
Hereditary breast and ovarian cancer (HBOC) educational materials for organization staff
Hereditary breast and ovarian cancer (HBOC) educational materials for patient/community
Other resources for Hereditary breast and ovarian cancer (HBOC)

4. In what ways do you educate community members about hereditary breast and ovarian cancer :*
Check all that apply
- As part of one to one patient education (one patient at a time)
- As part of community education
- Not Sure
- We do not yet educate community members about hereditary breast and ovarian cancer
5. In the past year, how often have you discussed hereditary breast and ovarian cancer with an individual patient or community member?*
- At least 2-3 times a week
- Once a week
- 2-3 times a month
- Once a month
- 2-3 times a year
- Once a year
- Less than once a year
- Never
6. In the past year, how often have you discussed hereditary breast and ovarian cancer in community education / outreach?*
- At least 2-3 times a week
- Once a week
- 2-3 times a month
- Once a month
- 2-3 times a year
- Once a year
- Less than once a year
- Never

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Section 5: Population Served
Totals do not need to add up to 100%
1. Please indicate what proportion of the population you work/ volunteer with are Hispanic/Latino:*
- 0%-25%
- 26%-50%
- 51%-75%
- 76%-100%
- Don't Know
2 . Please indicate what proportion of the population you work/volunteer with are American Indian or Alaska Native:*
- 0%-25%
- 26%-50%
- 51%-75%
- 76%-100%
- Don't Know
3. Please indicate what proportion of the population you work/volunteer with are Black or African American:*
- 0%-25%
- 26%-50%
- 51%-75%
- 76%-100%
- Don't Know
4. Please indicate what proportion of the population you work/volunteer with are Non-Hispanic White:*
- 0%-25%
- 26%-50%
- 51%-75%
- 76%-100%
- Don't Know
5. Please indicate what proportion of the population you work/volunteer with are Asian:*
- 0%-25%
- 26%-50%
- 51%-75%
- 76%-100%
- Don't Know
6. Please indicate what proportion of the population you work/volunteer with are Native Hawaiian/Pacific Islander:*
- 0%-25%
- 26%-50%
- 51%-75%
- 76%-100%
- Don't Know
7. Please indicate what proportion of the population you work/volunteer with are male*
- 0%-25%
- 26%-50%
- 51%-75%
- 76%-100%
- Don't Know
8. Please indicate what proportion of the population you work/volunteer with are female*
- 0%-25%
- 26%-50%
- 51%-75%
- 76%-100%
- Don't Know
9. Please indicate what proportion of the population you work/volunteer with are publically insured:*
- 0%-25%
- 26%-50%
- 51%-75%
- 76%-100%
- Don't Know
10. Please indicate what proportion of the population you work/volunteer with are privately uninsured:*
- 0%-25%
- 26%-50%
- 51%-75%
- 76%-100%
- Don't Know
11. Please indicate what proportion of the population you work/volunteer with do not have insurance:*
- 0%-25%
- 26%-50%
- 51%-75%
- 76%-100%
- Don't Know

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Section 6: Training Goals
Please describe a personal goal you hope to achieve by participating in this training program*
Please describe a professional goal you hope to achieve by participating in this training program by completing this training*
How did you hear about us?*
- Website
- Prior trainee
- Employer
- Conference/ symposium
- Friend
- Listserve
What type of reminders do you prefer?*
Check all that apply
- Text message (whatsapp) reminders
- Email reminders
- Other
Please Specify:

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Section 7: Attitudes and Opinions about Genetic Testing
Genetic counseling examines the hereditary basis of cancer and offers support and guidance to individuals considering whether or not to undergo genetic testing.

We would like to know how much you have heard about genetic counseling and different cancers before you heard about this study.*

	Almost Nothing	Relatively Little	A Fair Amount	A Lot
How much have you heard or read about genetic counseling for inherited disease?
How much have you heard or read about genetic counseling for cancer?
How much have you heard or read about genetic counseling for ovarian cancer?
How much have you heard or read about genetic counseling for colon cancer?

Have you ever heard or read about genetic counseling from:*
Yes No Not Sure
A healthcare professional
A family member
A friend
Television/commercials
Newspaper or magazine
Other
If you selected other above please specify:

The next questions are to find out how much you may already know about genes for cancer. This is not a test. This information will help us to evaluate our education and counseling programs.*

Please try to complete all items even if you are unsure of an answer

	True	False	Don't Know
A father can pass down an altered breast cancer gene to his children.
One half of all breast cancer cases occur in women who have an altered breast cancer gene.
All women who have an altered breast cancer gene get cancer.
A woman who does not have an altered breast cancer gene can still get breast or ovarian cancer.
Early-onset breast cancer is more likely due to an altered breast cancer gene than is late-onset breast cancer.
One in 10 women has a breast cancer gene mutation.
A woman who has an altered breast cancer gene has a higher ovarian cancer risk.
Having ovaries removed will definitely prevent ovarian cancer.
A woman who has her breasts removed can still get breast cancer.
Ovarian cancer screening tests often do not detect cancer until after it spreads.

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Section 8: Genetic Literacy Scale
The words below are words related to genetics that people sometimes struggle with. We first list a word and then ask how familiar you are with each word. Marking "7" on the scale reflects that you strongly agree, marking "1" on the scale means that you strongly disagree. Please choose the number that best reflects your opinion. The second question asks you to choose the best word which fills in the blank.
Genetic*
I am familiar with this term:
Strongly disagree 1. 2. 3. 4. 5. 6. Strongly agree 7.
Genetics is the study of how living things receive common traits from previous ______________.*
- Generations
- Experiences
- Exposures
- Germinations
Chromosome*
I am familiar with this term:
Strongly disagree 1. 2. 3. 4. 5. 6. Strongly agree 7.
A chromosome contains all of our ____________________ material.*
- Genetic
- Digestive
- Cellular
- Brain
Susceptibility*
I am familiar with this term:
Strongly disagree 1. 2. 3. 4. 5. 6. Strongly agree 7.
Susceptibility to a disease means you _______________ get the disease.*
- Eventually will
- Definitely will
- Might
- Will never
Mutation*
I am familiar with this term:
Strongly disagree 1. 2. 3. 4. 5. 6. Strongly agree 7.
A mutation is a change in your ______________.*
- Intestine
- Skin
- DNA
- Blood
Variation*
I am familiar with this term:
Strongly disagree 1. 2. 3. 4. 5. 6. Strongly agree 7.
Having a variation in the genetic code will lead to disease _____________.*
- All of the time
- Some of the time
- Never
- Only in animals
Abnormality*
I am familiar with this term:
Strongly disagree 1. 2. 3. 4. 5. 6. Strongly agree 7.
__________________ is an abnormality.*
- A trachea
- Brown hair
- Trisomy
- Blood pressure
Heredity*
I am familiar with this term:
Strongly disagree 1. 2. 3. 4. 5. 6. Strongly agree 7.
Heredity is the transfer of characteristics from _________________.*
- The environment to the person
- The sick to the healthy
- Parent to child
- Teacher to student
Sporadic*
I am familiar with this term:
Strongly disagree 1. 2. 3. 4. 5. 6. Strongly agree 7.
A genetic disease that occurs without ___________is considered sporadic.*
- Symptoms
- A family history
- A diagnosis
- Medication

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Section 9: Genetic Counseling and Testing (Perceived Benefits and Barriers)

We have a few more questions about your thoughts about genetic counseling and testing. Let us know how much you agree or disagree with each one.*

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
Genetic counseling would help Latinas in my community understand more about their risks for cancer
Latinas in my community would not be able to pay for something like genetic counseling.
If a genetic counselor spoke Spanish, Latinas in my community would be more likely to have genetic counseling.
If Latinas in my community had to travel to a hospital to have genetic counseling, they would not go.
If Latinas in my community knew they carried a gene for hereditary breast and ovarian cancer, they would be motivated to perform breast self-examination more frequently.
If Latinas in my community were found to carry a gene for hereditary breast and ovarian cancer, it would help their daughters or sisters decide whether to undergo genetic testing.
For Latinas in my community, knowing that they carry a gene for hereditary breast and ovarian cancer would help them decide whether to go for more frequent mammograms.
If Latinas in my community knew whether or not they carried a gene for hereditary breast and ovarian cancer, their senses of uncertainty about the future would be reduced.
If Latinas in my community knew whether or not they carried a gene for hereditary breast and ovarian cancer, their senses of personal control would be increased.
If Latinas in my community knew that they did not carry a gene for hereditary breast and ovarian cancer, their qualities of life would be greatly improved.
If Latinas in my community knew that they did not carry a gene for hereditary breast and ovarian cancer, their concerns about developing (having a recurrence of) breast cancer would be reduced.
If Latinas in my community knew that they did not carry a gene for hereditary breast and ovarian cancer, it would improve how they feel about themselves.
If Latinas in my community knew that they carried a gene for hereditary breast and ovarian cancer, their concerns about their female offspring developing breast cancer would increase.
If Latinas in my community knew that they did not carry a gene for hereditary breast and ovarian cancer, it would not be helpful since their offspring could still develop breast cancer.
If Latinas in my community knew that they carried a gene for hereditary breast and ovarian cancer, it would cause them to worry more about other family members who could be carriers (e.g., mother, sisters, and daughters).
For Latinas in my community, concerns about developing breast cancer would increase if they knew that they carried a gene for hereditary breast and ovarian cancer.
If Latinas in my community knew that they did not carry a gene for hereditary breast and ovarian cancer, it would not be helpful since they could still develop breast cancer.
If Latinas in my community knew that they did not carry a gene for hereditary breast and ovarian cancer, it would not reduce their concerns about developing breast cancer.
If Latinas in my community were found to carry a gene for hereditary breast and ovarian cancer, it would jeopardize their insurance coverage or lead to problems with their employers.
If Latinas in my community knew that they carried a gene for hereditary breast and ovarian cancer, it would leave them in a state of hopelessness and despair.
If Latinas in my community knew that they carried a gene for hereditary breast and ovarian cancer, it would worsen their quality of life.
If Latinas in my community were found to carry a gene for hereditary breast and ovarian cancer, it would cause others to view them negatively.
Latinas in my community already know their chances of getting breast cancer, so they wouldn't learn anything more from being tested.
Testing is not worthwhile because it could yield inconclusive results about whether Latinas in my community carry a gene for hereditary breast and ovarian cancer.

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Section 10: Self-Efficacy

Please indicate your confidence about your ability to accomplish the following:*

	Not at all confident 1.	2	3	4	5	6	7	8	9	Extremely Confident 10.
How confident do you feel about communicating with women you work with about hereditary breast and ovarian cancer?
How confident do you feel about educating a patient about hereditary breast and ovarian cancer?
How confident do you feel about conducting a community education session about hereditary breast and ovarian cancer?
How confident do you feel about identifying a patient at high risk for hereditary breast and ovarian cancer?
How confident do you feel about identifying genetic services in your local area?
How confident do you feel about referring a patient at high risk for hereditary breast and ovarian cancer to genetic services?
How confident do you feel about navigating a patient at high risk for hereditary breast and ovarian cancer through use of genetic services?

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Section 11: Short Acculturation Scale for Hispanics (Marin Et Al Scale)

We would like to ask you some questions about languages you speak.*

	Only Spanish	More Spanish than English	Both Equally	More English than Spanish	Only English	Other?
a. In general, what language(s) do you read and speak?
b. What was the language(s) you used as a child?
c. What language(s) do you usually speak at home?
d. In which language(s) do you usually think?
e. What language(s) do you usually speak with your friends?
f. In what language(s) are the T.V. and Radio programs you usually watch?

If other language was selected, please indicate what other language(s):
Add additonal items by clicking the + button.

The next questions are about your friends. Please choose one response.*

	All Latinos/ Hispanics	More Latinos than Americans	About Half & Half	More Americans than Latinos	All Americans	Other?
a. Your closest friends are
b. You prefer going to social gatherings/parties at which the people are
c. If you could choose your children's friends you would want them to be

If other was selected, please indicate what other nationalities:
Add additional items by clicking the + button.
Comments
This field is for validation purposes and should be left unchanged.

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	Yes	No	Not Sure
A healthcare professional
A family member
A friend
Television/commercials
Newspaper or magazine
Other

Step 1 of 11 - Participation Requirements

Section 1: Participation Requirements

Thank you for your interest in participating.

Thank you for your interest in participating.

Thank you for your interest in participating.

Thank you for your interest in participating.

Reference One

Reference Two

Thank you for your interest in participating.

Section 2: Background Information

Section 3: Educational Background

Section 4: Workplace Setting

Section 5: Population Served

Section 6: Training Goals

Section 7: Attitudes and Opinions about Genetic Testing

Section 8: Genetic Literacy Scale

Section 9: Genetic Counseling and Testing (Perceived Benefits and Barriers)

Section 10: Self-Efficacy

Section 11: Short Acculturation Scale for Hispanics (Marin Et Al Scale)