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Grant Programs for Fertility Assistance
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Angelique Arrieta
Gary Pecho
Dr. Mary Kikilas
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Confidential Survey
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We thank you for your feedback and will keep all personal data confidential. Our organization is actively seeking funding to further our mission and impact. Data and evidence-based practice is crucial to our mission. By providing us your feedback we can better demonstrate the need for our charity and our commitment to assisting those struggling with out-of-pocket fertility costs. Below are the descriptions of the grants we will be providing, to be referenced as needed. The survey consists of 16 questions and are tailored to collect data concerning the individual experiencing infertility, fertility treatments, and/or fertility preservation as well as their partner/spouse if/when applicable. We also welcome any additional information that is useful to the overall mission.
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Fertility Treatments/Adoption Fees Grant: Contributions for this program will be primarily used to provide funds to individuals for the larger costs associated with fertility treatments not covered by insurance. These costs can include in vitro fertilization (IVF) cycles, and other fertility treatments and associated costs, and in cases where individuals are unable to conceive a child, adoption fees.
Fertility Preservation Grant: The contributions for this program will be primarily used to provide funds to individuals for fertility preservation, when medically necessary and not covered by insurance, including medications and egg, sperm, embryo, and reproductive tissues freezing/storing/monitoring/retrieval.
Fertility Emergency Fund Microgrant: Contributions for this program will be primarily used to provide emergency funds to individuals with an immediate need for time sensitive fertility medications, medical equipment, tests, and other fertility treatments not covered by insurance. This program will be monitored and approved daily to provide immediate funds.
Fertility Debt Assistance Grant: Contributions for this program will be primarily used to assist with debt associated with out-of-pocket fertility costs. Including current or past debt specifically related to medical infertility treatments and costs.
1. Which of the following best describes your experience with infertility, fertility treatments or fertility preservation
*
Individual Experiencing Infertility, Fertility Treatments or Preservation
Partner/Spouse of Individual Experiencing Infertility, Fertility Treatments or Preservation
Family Member of Individual Experiencing Infertility, Fertility Treatments or Preservation
Friend of Individual Experiencing Infertility, Fertility Treatments or Preservation
Healthcare Provider
Other – please specify below under 1a.
1a. Other (please specify.):
2. Gender of individual experiencing infertility, fertility treatments or fertility preservation
*
Male
Female
Transgender male
Transgender female
Nonbinary/nonconforming
Prefer not to say
Not Applicable
3. If applicable, gender of partner/spouse of individual experiencing infertility, fertility treatments or fertility preservation
*
Male
Female
Transgender male
Transgender female
Nonbinary/nonconforming
Prefer not to say
Not Applicable
4. Age of individual experiencing infertility, fertility treatments or fertility preservation
*
18-25
26-35
36-45
46-55
56-65
Over 65
Prefer not to say
Not Applicable
5. If applicable, age of partner/spouse of individual experiencing infertility, fertility treatments or fertility preservation
*
18-25
26-35
36-45
46-55
56-65
Over 65
Prefer not to say
Not Applicable
6. State of residence of individual experiencing infertility, fertility treatments or fertility preservation
*
Next
would fertility past?
7. Has the individual experiencing infertility and/or fertility treatments been diagnosed with infertility?
Yes
No – please see 7a.
N/A
7a. If no, and if applicable how long has the individual tried to conceive unassisted?
8. If applicable, has the partner/spouse of the person experiencing infertility and/or fertility treatments been tested for infertility
Yes
No
N/A
9. Has the individual experiencing infertility had fertility treatments in the past?
Yes – please see 9a. & 9b.
No
Not Applicable
9a. If yes, how long did the individual try to conceive assisted?
9b. If yes, did the treatments result in a pregnancy?
10. Which Grant Best Fits Your Needs
*
Fertility Treatment/Adoption Fees
Fertility Preservation
Emergency Fertility Costs – Microgrant
Fertility Debt Assistance
None, I Just Want to Help by Providing Data of My Experience
Other – I need assistance not covered by these grants (please specify below 10a.)
Select All That Apply
10a. Other (please specify):
11. If applicable, how much money do you currently need for fertility treatments and or fertility preservation?
Please do not include any amounts covered by insurance.
12. If applicable, how much money do you anticipate needing in the future for fertility treatments and or fertility preservation?
Please do not include any amounts covered by insurance.
13. If applicable, have you in the past experienced fertility treatment costs and or fertility preservation costs that would have significantly impacted or delayed treatments? If yes, please advise how much money was needed.
Please do not include any amounts covered by insurance.
14. If applicable, how much debt are you currently carrying due to fertility treatments and or fertility preservation?
Please include any amounts still owed and/or credit card debt.
15. What do you want people to know about infertility, fertility treatments or fertility preservation as you have experienced it?
16. Any additional comments you would like to share regarding your experience with infertility and/or fertility treatments or fertility preservation.
Submit