ACCO - PedMark Survey

Submit your feedback below.

Contact Information

First Name

Last Name

Phone

Email

Relationship to child with cancer

ParentStep-parentFoster ParentGrandparent Other family member Other caregiver Self

Patient Information

First Name

Age at Diagnosis

Current Age

Current Status

Currently on treatmentNo Evidence of Disease Survivor Passed Other

Diagnosis

Year Diagnosed

Primary Treatment Facility

Secondary Treatment Facility (if applicable)

Tertiary Treatment Facility (if applicable)

1. Did you/your child receive cisplatin as part of chemotherapy treatment?

Yes No Not sure

2. If yes, was hearing protection discussed before you/your child's cisplatin treatment began?

Yes No Not sure N/A

3. Did you/your child receive auditory/hearing screening prior to receiving cisplatin?

Yes No Not sure N/A

4. If you/your child received cisplatin as part of chemotherapy treatment, did you/your child also receive a drug with the intent to reduce hearing loss potentially caused by cisplatin?

Yes No Not sure N/A

5. If yes, did you/your child receive PEDMARK® in conjunction with cisplatin with the intent to reduce hearing loss?

Yes No Not sure N/A

6. Did you/your child receive a PEDMARK® alternative drug in conjunction with cisplatin with the intent to reduce hearing loss?

Yes No Not sure N/A

7. If you received a PEDMARK® alternative drug, please describe the drug below.

8. Did you/your child receive auditory/hearing screening upon completion of receiving cisplatin?

Yes No Not sure N/A

9. Have you/your child been diagnosed with cisplatin-related hearing loss?

Yes No Not sure N/A

Thank you so much for your time and for sharing this important information.

Contact Information