Europen map form

Consent

I agree that the LTFU care service I work(ed) in appears on the PanCare European Map of LTFU care

Country of employment

Type country of employment here:

Name of the LTFU care center you work(ed) in

Website of LTFU care center

How are the LTFU care clinic(s) in your country organized?

Please specify:

Does the start of LTFU care depend on the end date of diagnosis or end date of treatment?

Diagnosis
End of treatment

How many years after diagnosis?

… years after diagnosis. Put in the number of years, use 0 for a start directly after diagnosis or within the first year

How many years after end of treatment?

… years after treatment. Put in the number of years, use 0 for a start after treatment or within the first year

For what period is LTFU care provided to survivors?

Survivors are only seen once
Until the survivor reaches a certain age
Until a certain number of years have passed since the diagnosis/treatment
Survivorship care is offered lifelong, independent of the survivor’s age and time since diagnosis/treatment
Other
Prefer not to answer

Until which age?

How many years?

If other, please speficy:

At what frequency are follow-up care consultations provided to a survivor?

Please specify

Which facilities are available to carry out LTFU-care?

Please consider the facilities that are available within LTFU care service, within the hospital/institution the LTFU-Care clinic belongs to and in another hospital/institution.

If other, please specify

What does the provided LTFU care entail?

Please specify

Is there a dedicated healthcare professional who directs the LTFU care of survivors and if so what does this person do?

Who is the dedicated healthcare professional?

(Medical) oncologist/haematologist
Paediatric oncologist/haematologist
Third ChoiceClinical nurse specialist/senior nurse/nurse
Advanced practice provider (e.g. nurse practitioner, physician’s assistant
Administration officer working inside the health care clinic
General practitioner
A patient/survivor organisation
Other

What does this person do:

Who finances the LTFU care e.g. how are the costs of visits and performed tests covered?

The LTFU care service
Fully covered by health care insurance of the survivor/a national health care system or other funding
Partially covered by health care insurance and partly by survivor
Fully covered by survivors or carers themselves
Other
I dont know
Prefer not to answer

Please specify

What is the provided LTFU care based upon?

Please specify

Does your follow-up care service facilitate peer-to-peer support from other CAYA cancer survivors?

Yes
No
I don’t know

Does your follow-up care service facilitate contact with relevant patient organisations for survivors?

Yes
No
I don’t know

Yes, to the following organisations

European Map form