You were diagnosed with testicular cancer in 2000 or later You were diagnosed with testicular cancer in 2000 or later Yes No

Have you been diagnosed with any other significant health conditions?

You were diagnosed with kidney cancer in 2000 or later You were diagnosed with kidney cancer in 2000 or later Yes No

Have you ever been informed that your water is contaminated? Have you ever been informed that your water is contaminated? Yes No

Your loved one died within the last 2 years (since 2023) from kidney or testicular cancer Your loved one died within the last 2 years (since 2023) from kidney or testicular cancer Yes No

Do you know the water source that was contaminated? Do you know the water source that was contaminated? Yes No

Have you ever been informed that your water is contaminated? Have you ever been informed that your water is contaminated? Yes No

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Last Name

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Select Case Type Select Case TypeAsbestos-related MesotheliomaContaminated Water From Firefighting Foam (AFFF)Hair Relaxer and Beauty ProductsTalcum Powder-related Ovarian Cancer