Thank you for your interest in the Electronic Surviving Cancer Competently Intervention Program (eSCCIP; pronounced “e-skip”). Please answer the following questions and click Submit when you are finished.

Submitting this interest form does not guarantee that you will be able to participate in the study. It will allow us to save this data and contact you soon to determine if you may be eligible for the study. Please provide accurate answers to these questions.

If you meet initial eligibility requirements, we may contact you by phone to discuss possible next steps for being in this study. We may also discuss this with you in person, during an appointment for your child at the hospital or at another time that is convenient for you.

If you prefer to talk to someone on the phone before completing this form, please contact the coordinator at your site listed here Monday - Friday during normal work hours of 8:00 AM - 5:00 PM:

• Nemours Children’s Health: Angel Munoz Osorio, phone 302-333-5761
• MD Anderson Children’s Cancer Hospital: Martha Askins, phone 713-794-4467
• Children's Hospital Los Angeles: Mariela Rojas, phone 323-361-7287