Community Liaison Application Form

Breast Cancer Network Australia

Breast Cancer Network Australia (BCNA) is informed and driven by women who have experienced breast cancer. Community Liaisons draw from their personal breast cancer experience and the knowledge gained through the Community Liaison Training Program to represent BCNA in local communities across Australia. This helps more Australians to understand the lived experience of breast cancer, how BCNA supports women and their families, and the availability of our free resources for women with breast cancer.

It is recognised not everyone’s experience is straightforward; however as an initial starting point for us to better understand your personal experience try to answer the questions on this form as completely as you can.

You are able to complete the form on your computer by typing answers into the grey shaded areas of the form. Once you have completed the form, save the document and return it tothe Community Programs team via email mail to 293 Camberwell Rd,
Camberwell VIC 3124.

Part 1: Personal and Contact Details

Title (please select):Ms Mrs Miss Mr Dr
Family name: Given name:
Preferred name:
Address:
Town/suburb: State: Postcode:
Telephone H () W () Mobile:
Email:
Date of birth: / /19
Relationship status:
Single Married Partner (opposite sex) Partner (same sex) Widowed
Which language/s do you speak other than English?
Next of kin contact details:
Name: Relationship: Contact Number:
Part 2: About You
Which best describes where you live?
Metropolitan Regional Rural Remote
Which of the following best describes your experience to breast cancer:
I have been diagnosed with breast cancer
I have not been diagnosed with breast cancer but have a strong family history
I am a family member / friend of someone diagnosed with breast cancer
If you are a family member/friend please select from the drop down box the appropriate option describing your relationship to the person diagnosed: - None selected -PartnerMotherSisterDaughterGrandmotherAuntCousinNeiceFemale friendMale relativeMale friend
Do you have any children? If so, how many and what age/s.
If applicable, number of children after diagnosis

Part 3: Motivation & Interests

This section gives you the opportunity to describe your experiences, skills and attributes which demonstrate your suitability as a Community Liaison. You may use dot points for clarity or write in brief
3.1Why are you interested in being a BCNA Community Liaison?
3.2What skills/experiences and/or traits do you have which will assist you to participate in the role?
3.3Are there any specific breast cancer issues you hope to promote as a Community Liaison?
Young women (<40) Rural/remote Access to treatment & care
Financial issues Health Professional interaction Family history
Peer support Impact on familyOther:
Further comments:
3.4Can you describe how BCNA has supported you and/or your family?
3.5What is your availability? Are you able to participate in activities during business hours?

Part 4: Local Community Involvement

BCNA Community Liaisons are our connection to local communities across Australia. This section gives you the opportunity to describe your community relationships. This may include your involvement with local groups and/or services and relationships you may have with community organisations and local businesses which you anticipate will support you in raising awareness of the impact of breast cancer.
4.2Are you involved or aware of other relevant community groups or services?
4.3Please advise the areas of involvement which interest you:
Public awareness Health Professional awareness Fundraising Support Groups
4.4Is there anything you would like to tell us about how you could approach raising awareness in your local community?
4.5Is there any additional information you would like to share about yourself in relation to being a BCNA Community Liaison in your local area?

Part 5: Background Information

We are interested to understand your professional background and other experiences and training which would be relevant to the role.
5.1Please select the appropriate option regarding your education level:- None -School CertificateTrade CertificateUndergraduatePostgraduate
5.2Have you undertaken any relevant training or education activities?
No Yes – Year & Where:
Detail:
5.3Please tell us about your work background.

Part 6: Diagnosis & Treatment

If you are a family member/friend of someone diagnosed go to Part 7: Confirmation of Application

This section asks for further information about your diagnosis and treatment to help better understand your experience.
6.1Please select the appropriate option regarding your diagnosis experience (you may select more than one) and include the month and year of your diagnosis.
Early/primary breast cancerMonth/Year:
DCIS/ LCISMonth/Year:
Another early/primary breast cancer diagnosis (local recurrence)Month/Year:
Secondary breast cancer / advanced breast cancer/ metastatic diseaseMonth/Year:
Family history Month/Year:
BRCA 1 mutation BRCA 2 mutation multiple relatives with breast cancer
Other (eg. Inflammatory breast cancer, Paget’s Disease)Month/Year:
Please specify:
Further comments relating to your diagnosis:
6.2How was your breast cancer firstdetected?
Self examinationRoutine mammogram
Doctor’s examination BreastScreen
Other, please specify:
6.3What type of surgery did you have?
None Prophylactic mastectomy
Mastectomy Bilateral mastectomy
Conservative surgery (lumpectomy) Axillary clearance
6.4Did you have further treatment after your diagnosis? No Yes, please indicate:
Radiotherapy Hormone therapy (eg. Tamoxifen)
Chemotherapy Other, please specify:
Further comments relating to your treatment:

Part 7: Confirmation of Application

I am interested in participating in BCNA’s Community Liaison Training. I understand the information provided in my application will be used for the purpose of the program, to ascertain my suitability for the role and to identify appropriate opportunities for my involvement.
Date:

Thank you for your interest and please retain a copy for your records.

BCNA will acknowledge receipt of your application and will advise

the next stage of the application process.

Breast Cancer Network Australia

293 Camberwell Rd, Camberwell Victoria Telephone: 1800 500 258 Internet:

Last Updated: July 2011 Page 1 of 3