ࡱ> AC@5@ 40bjbj22 +6XX,:::8rTJ t <O$R? QI II  ]%%%IR  %I%$%II  YO:FIs0I.IIPL  % l OL L L  d$The Faces of CML Questionnaire (Click in the gray areas to enter your information. You may also Tab to move between fields.) Name:  FORMTEXT       I am a CML  FORMCHECKBOX  Patient  FORMCHECKBOX  Caregiver  FORMCHECKBOX  Family Member  FORMCHECKBOX  Other If Other is selected, please explain:  FORMTEXT       City/State/Country:  FORMTEXT       Briefly tell us your story (500 words or less). (You might include date and age when diagnosed, you and your family s initial reaction, finding treatment, how CML has impacted the way you or your family live your life, lessons learned, etc.)  FORMTEXT       NOTE: The Word Count& option is available on the Tools dropdown menu above. If you only had 30 seconds to tell someone about CML and its treatment, what would you say? (Assume this person has no knowledge whatsoever about CML.)  FORMTEXT       In what ways do you wish to see CML brought to the forefront in the battle against cancer?  FORMTEXT       Is there an obvious need that you see going unmet as a CML patient, family member, or caregiver?  FORMTEXT       Name one  life lesson learned on your CML journey:  FORMTEXT       Email completed questionnaires to gstephens@carolynshope.org Please attach> " $ . 0 > D Z \ ǯtZ=,,!ha[5B*OJQJ\^Jph8jh.h/TB*OJQJU\^JmHnHphu3jh.h`0B*OJQJU\^Jph$h.h/TB*OJQJ\^Jph-jh.h/TB*OJQJU\^Jph!h/T5B*OJQJ\^Jph/h+h/T5B*CJOJQJ\^JaJph$h=h=B*OJQJ\^Jphh=B*OJQJ\^Jph)h/T5B*CJOJQJ\^JaJph>@ D @   h      7$8$H$gd+ 7$8$H$gda[ 7$8$H$gd/T/20\ ^ z | ~   , . 0 > F P n ٽ١مtXtBt*h+h+56B*OJQJ\^Jph6jh+h+5B*OJQJU\^Jph!h+5B*OJQJ\^Jph6jnh+h+5B*OJQJU\^Jph6jhH8hH85B*OJQJU\^Jph6jh+h+5B*OJQJU\^Jph!ha[5B*OJQJ\^Jph*jha[5B*OJQJU\^Jph Ī׍|d|V@/!h.h/TB*OJQJ^Jph*jh.h/TB*OJQJU^Jphh/TB*OJQJ^Jph/h+h/T5B*CJOJQJ\^JaJph!h/T5B*OJQJ\^Jph8jh.ha[B*OJQJU\^JmHnHphu3jVh.h+B*OJQJU\^Jph$h.ha[B*OJQJ\^Jph-jh.ha[B*OJQJU\^Jph!h=5B*OJQJ\^Jph     @ H h  ѶѨn`O8%$h.h`0B*OJQJ\^Jph-jh.h`0B*OJQJU\^Jph!h+h/TB*OJQJ^Jphh+B*OJQJ^Jph!h/T5B*OJQJ\^Jph!h/T5B*OJQJ\^Jph/h+h/T5B*CJOJQJ\^JaJphh/TB*OJQJ^Jph5jh.h/TB*OJQJU^JmHnHphu*jh.h/TB*OJQJU^Jph0jh.h`0B*OJQJU^Jph      & . 0 D | αΞraM:a:a'$h+h+6B*OJQJ^Jph$h+h+5B*OJQJ^Jph'h+h+5>*B*OJQJ^Jph!h+h+B*OJQJ^Jph'h+h+56B*OJQJ^Jph/h+h/T5B*CJOJQJ\^JaJph$h.h/TB*OJQJ\^Jph8jh.h`0B*OJQJU\^JmHnHphu-jh.h`0B*OJQJU\^Jph3j4h.h`0B*OJQJU\^Jph l  ĶrUBğ$h.h/TB*OJQJ\^Jph8jh.h`0B*OJQJU\^JmHnHphu3jh.h`0B*OJQJU\^Jph$h.h`0B*OJQJ\^Jph-jh.h`0B*OJQJU\^Jphh/TB*OJQJ^Jph!h/T5B*OJQJ\^Jph/h+h/T5B*CJOJQJ\^JaJph$h+h+B*OJQJ\^JphBDαΞubHαΞu/0jh.h`05B*OJQJU]^Jph3jh.h`0B*OJQJU\^Jph$h.h`0B*OJQJ\^Jph!h/T5B*OJQJ\^Jph/h+h/T5B*CJOJQJ\^JaJph$h.h/TB*OJQJ\^Jph8jh.h`0B*OJQJU\^JmHnHphu-jh.h`0B*OJQJU\^Jph3j h.h`0B*OJQJU\^JphBjl(((\))2*4*,,/.0002040$a$gd 7$8$H$gd/TDXZ\fhjln((:((϶scRAs?s.s!ha[6B*OJQJ]^JphU!h6B*OJQJ]^Jph!h5B*OJQJ\^Jphh`0h5OJQJ\^J!h/T6B*OJQJ]^Jph'h.h/T5B*OJQJ]^Jph;jh.h`05B*OJQJU]^JmHnHphu0jh.h`05B*OJQJU]^Jph6jh.h`05B*OJQJU]^Jph'h.h`05B*OJQJ]^Jph a photograph with your email for inclusion. Accepted formats include JPEG, TIFF and GIF. May we contact you by phone? If so, please include your contact information here: Phone:  FORMTEXT       (please include country code if applicable) Postal Address:  FORMTEXT       Information collected through this questionnaire will be used for inclusion in a document/booklet called  Faces of CML: Stories of Courage, Hope, and Inspiration from the Worldwide CML Community . This document s initial usage will be for the LiveSTRONG"! Summit, to be held July 24  27, 2008, Ohio State University, Columbus, OH, USA. By submitting a completed questionnaire, participants acknowledge that the information they include will be shared with delegates to the LiveSTRONG"! Summit, the Lance Armstrong Foundation, Carolyn s Hope, Inc., CMLConnection"!, and their subsidiaries. Participants agree to hold harmless Carolyn s Hope, Inc. and CMLConnection"! concerning any dissemination of the submitted information. 2008 Carolyn s Hope, Inc./CMLConnection"! ((j)l))))))) * * *"*$*.*0*4***++ʼʎ}ʼgʎ}YKY7'h/T56B*OJQJ\]^Jphh`0B*OJQJ^Jphh/TB*OJQJ^Jph*jh.h`0OJQJU\^J!h`05B*OJQJ\^Jph/jh.h`0OJQJU\^JmHnHu*jh.h`0OJQJU\^Jh.h`0OJQJ\^J$jh.h`0OJQJU\^J!h/T5B*OJQJ\^Jph!h6B*OJQJ]^Jph+++V,X,,,,,--..///.02040ɻɻɩhhhCJaJ#h/TB*CJOJQJ^JaJph#h`0B*CJOJQJ^JaJphh`0B*OJQJ^Jphh/TB*OJQJ^Jph'h/T56B*OJQJ\]^Jph'h`056B*OJQJ\]^Jph)0P:p=/ =!"#$%DName TITLE CASEtDCheck1tDCheck2tDCheck3tDCheck4tDText2jDLocationxAlthough this form requests City and State, you may enter Province, Region, or any other applicable location designator.tDStoryxDseconds|D ForefronttDUnmet~D lifelessontDText1rDAddr@@@ NormalCJ_HaJmH sH tH DAD Default Paragraph FontRiR  Table Normal4 l4a (k(No List4@4 Header  !4 @4 Footer  ! 6~ Z[ _xrXlmZ[\jk  0000000p00000000000p0000 000 0 0p00 0 0000 00 0 0 000p@0@% _x O90Z M90M90M900O900M90h"M90w+++.\  D(+40 40 20 FRXo{xr~Xdj FG G G G FFFFFFFFFNameCheck1Check2Check3Check4Text2LocationStoryseconds ForefrontUnmet lifelessonText1AddrGpysY  Yk !&W!!& E!&DJUU_chh   =*urn:schemas-microsoft-com:office:smarttags PlaceType= *urn:schemas-microsoft-com:office:smarttags PlaceNameB*urn:schemas-microsoft-com:office:smarttagscountry-region9*urn:schemas-microsoft-com:office:smarttagsState8 *urn:schemas-microsoft-com:office:smarttagsdate8 *urn:schemas-microsoft-com:office:smarttagsCity9 *urn:schemas-microsoft-com:office:smarttagsplace 2008247DayMonthYear    >K    #( _f    3333[      Greg Stephens `02H8a[/T==f+5. G   @%L PP P PPP(UnknownGz Times New Roman5Symbol3& z ArialMTimesNewRoman,BoldCTimesNewRomanUTimesNewRomanPS-BoldMTQTimesNewRoman,ItalicYTimesNewRoman,BoldItalic"qhƦƦUU!24d3K)?=The Faces of CML Questionnaire Greg Stephens Greg StephensOh+'0  8D ` l xThe Faces of CML Questionnairehe Greg StephensMLregregFaces Questionnaire 080620iGreg Stephensna6egMicrosoft Word 10.0@`4<@M@FOU՜.+,0 hp|  aA The Faces of CML Questionnaire Title  !"#%&'()*+,-./12345679:;<=>?BRoot Entry F>\ODData 1Table$WordDocument+6SummaryInformation(0DocumentSummaryInformation88CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q