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Cervical Cancer Study
Patient Survey–Follow-Up
Form Approved
OMB Control No. 0920-xxxx
Expiration Date: xx/xx/20xx
Approximately 18 months (40 months) ago, when you visited [CLINIC NAME] for your Pap
test, you agreed to participate in the CDC Cervical Cancer (Cx3) Study. As part of the study
you received an HPV test along with your Pap test and you filled out a survey while you were
at the clinic. This is the first (second) of two follow-up surveys that we are conducting to
understand women’s views and experiences about cervical cancer screening. Answering
these questions will help CDC create new materials to help women protect themselves from
cervical cancer.
¾ The survey should take about 10 minutes to complete.
¾ Your name is not included on your survey.
¾ Your answers will be kept private to the extent allowed by law.
¾ Answers from approximately 1,900 (1,500) women will be combined.
¾ Some of the questions are personal but provide important information for this
study.
¾ It is your choice to complete the survey. You may choose to skip any questions
that you do not want to answer.
¾ Only people connected with this survey will see your answers. Your doctor will
not see them.
¾ Your doctor will give you the same care, whether you choose to take the survey
or not.
We thank you very much for taking your time to take this survey for us.
When you are done, please put the survey into the enclosed
postage-paid envelope, and drop it in a mailbox.
Centers for Public Health Research and Evaluation
1100 Dexter Avenue N., Suite 400
Seattle, Washington 98109-3598
Public reporting burden of this collection of information varies from 8 to 12 minutes with an estimated average of 10 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and
reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road
NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (xxxx-xxxx)
G:\Controlled Files\PD\FG601906-01\SAQ-FU\HPV Follow-up Patient Survey Complete.doc
Cervical Cancer Study: Patient Survey
Page 1
PART A: Information About You and Your Health Care Visits
This part of the survey asks questions that will help us describe the survey participants.
Please write in or check (9) the best answer.
A1.
What is your date of birth?
MONTH
A2.
Which type of health insurance do you have?
Please 9 all that apply.
YEAR
Private insurance (Kaiser, Blue Cross, Aetna,
etc.)
Medicare (including Medicare managed care)
Medicaid / Medical Coupons
Military or Veterans Administration
Illinois Breast and Cervical Cancer Program
(BCCP)
No insurance (Self-pay for all health care
costs)
Other. Please specify: __________________
_______________________________________
A3.
About how many times have you gone to (CLINIC
NAME) for your health care in the past 12
months? Do not include visits for friends or family
members.
A4.
A5.
A6.
Have you visited other clinics or doctors’ offices in
the past 12 months for your health care?
Is (CLINIC NAME) the one you use most of the time
when you need to see a doctor?
Approximately 18 months (40 months) ago you
had a Pap test at (CLINIC NAME). After that Pap
test, when were you told to come back for your
next Pap test?
G:\Controlled Files\PD\FG601906-01\SAQ-FU\HPV Follow-up Patient Survey Complete.doc
Never
1 time
2-4 times
5-10 times
More than 10 times
Yes
No
Yes
No
As soon as possible
6 months
1 year
2 years
3 years
No one said when to come back again
I’m not sure or can’t remember
Cervical Cancer Study: Patient Survey
A7.
A8.
How many times have you had a Pap test in the
last 18 months (40 months)?
Did you have your most recent Pap test at (CLINIC
NAME)?
A9.
Page 2
None
1 Pap test
2 Pap tests
3 or more Pap tests
Don’t know
Yes
No
How many months ago was your last Pap test?
# of months ago
A10.
What were the results of your last Pap test?
A11.
How good or bad did you feel after getting the
results of your last Pap test? Please 9 only
Very good
Somewhat good
Neither good nor bad
Somewhat bad
Very bad
Very worried
Somewhat worried
Neither worried nor relieved
Somewhat relieved
Very relieved
Very happy
Somewhat happy
Neither happy nor unhappy
Somewhat unhappy
Very unhappy
one.
A12.
How worried or relieved did you feel after getting
the results of your last Pap test? Please 9 only
one.
A13.
How happy or unhappy did you feel after getting
the results of your last Pap test? Please 9 only
one.
G:\Controlled Files\PD\FG601906-01\SAQ-FU\HPV Follow-up Patient Survey Complete.doc
Normal
Abnormal
I’m not sure
I didn’t get any results
I was told I would be contacted if there was a
problem
Cervical Cancer Study: Patient Survey
A14.
Page 3
After you received the results of your last Pap
test, what did your doctor tell you to do? Please
9 only one box on each line.
Yes
No
Not sure
a.
Do nothing ............................................................
b.
Get another Pap test within 6 months ..................
c.
Have a test that takes a closer look at your
cervix (a colposcopy) ...........................................
d.
Have a biopsy.......................................................
e.
Have some other test or treatment.......................
a) What other test or treatment? __________________________________________________
A15.
In the last 18 months, has a doctor or nurse told
you that your Pap test was not normal?
A. How many months ago did you have the Pap
result that was not normal?
A16.
When do you expect to get your next Pap test?
Please 9 only one answer.
G:\Controlled Files\PD\FG601906-01\SAQ-FU\HPV Follow-up Patient Survey Complete.doc
Yes
No
I’m not sure
Go to Question A16.
# of months ago
In less than 3 months
In 3–6 months
In 6–9 months
In 9–12 months
In more than 12 months
Don‘t know
Cervical Cancer Study: Patient Survey
Page 4
PART B: Your Opinions About HPV and Pap Tests
B1.
B2.
Before today, have you ever heard of HPV? HPV
stands for Human Papillomavirus.
Yes
No
Go to Question B2.
Go to Question B12.
Please 9 all of the sources below where you learned about HPV.
B3.
Internet
Magazines
Pamphlets
Books
Health Department
Telephone Hotline
Partner
Friends
Family
Co-workers
Teacher
Health Care Provider
Family Planning Clinics
Planned Parenthood
Medical books/medical journals
Television
Radio
Other. Please specify: __________________________________
Please mark whether you agree, disagree, or are not sure about the following statements.
We are interested in your opinions and what
you may have heard about HPV.
Agree
Disagree
Not Sure
a.
There are many types of HPV..............................
b.
HPV causes HIV/AIDS .........................................
c.
Antibiotics can cure HPV......................................
d.
You can always tell when someone else has
HPV ......................................................................
e.
HPV can cause abnormal Pap tests ....................
f.
Only women get HPV...........................................
g.
HPV causes herpes .............................................
h.
HPV affects your ability to get pregnant...............
i.
HPV is a virus.......................................................
j.
Once you get HPV, you always have it................
k.
There are types of HPV that cause genital warts
l.
HPV can be cured ................................................
m.
You can get HPV from toilet seats .......................
n.
HPV is a sexually transmitted infection................
o.
There are types of HPV that cause cervical
cancer...................................................................
p.
HPV may go away by itself ..................................
G:\Controlled Files\PD\FG601906-01\SAQ-FU\HPV Follow-up Patient Survey Complete.doc
Cervical Cancer Study: Patient Survey
B4.
Agree
Disagree
Not Sure
q.
You can get HPV through poor personal
hygiene.................................................................
r.
Even if you do not see a wart, you can still give
HPV to someone else ..........................................
s.
Using a condom will lower the chance of giving
HPV to someone else ..........................................
t.
Lots of people have HPV .....................................
u.
You can have HPV for a long time without
knowing it .............................................................
v.
You can have more than one type of HPV...........
When you had your last Pap test, did you get an
HPV test at the same time?
A.
B.
C.
D.
B5.
Page 5
What was the result of your HPV test?
How good or bad did you feel after getting
the result of your HPV test?
How worried or relieved did you feel after
getting the result of your HPV test?
How happy or unhappy did you feel after
getting the result of your HPV test?
Have you ever been told by a health care provider
that you had HPV infection?
G:\Controlled Files\PD\FG601906-01\SAQ-FU\HPV Follow-up Patient Survey Complete.doc
Yes
No
Don’t Know
Go to Question B5.
HPV-Positive
HPV-Negative
I’m not sure
Go to Question B5.
Very good
Somewhat good
Neither good nor bad
Somewhat bad
Very bad
Very worried
Somewhat worried
Neither worried nor relieved
Somewhat relieved
Very relieved
Very happy
Somewhat happy
Neither happy nor unhappy
Somewhat unhappy
Very unhappy
Yes
No
Don’t know
Cervical Cancer Study: Patient Survey
B6.
B7.
B8.
B9.
B10.
B11.
Page 6
Would you want to get an HPV test the next time
you get a Pap test?
We’d like your opinion about getting an HPV test
along with your Pap test the next time you get a
Pap test. How good or bad will it be to get an HPV
test the next time you get a Pap test?
How useless or useful will it be to get an HPV test
next time you get a Pap test?
How comforting or worrying will it be to get an
HPV test next time you get a Pap test?
How wise or foolish will it be to get an HPV test
next time you get a Pap test?
Yes
No
Don’t know
Very good
Somewhat good
Neither good nor bad
Somewhat bad
Very bad
Very useless
Somewhat useless
Neither useless nor useful
Somewhat useful
Very useful
Very comforting
Somewhat comforting
Neither comforting nor worrying
Somewhat worrying
Very worrying
Very wise
Somewhat wise
Neither wise nor foolish
Somewhat foolish
Very foolish
Please 9 one box on each line to indicate how much you agree or disagree with the following
statements.
Getting an HPV test with your next
Pap test:
Strongly
Agree
Somewhat
Agree
Neither/
Not sure
Somewhat
Disagree
Strongly
Disagree
a.
Will give you peace of mind ................
b.
Will tell you whether you need to
worry if your Pap is abnormal .............
c.
Will be an unnecessary extra cost ......
d.
Is something your doctor thinks you
should have.........................................
e.
Will give you the best care available...
G:\Controlled Files\PD\FG601906-01\SAQ-FU\HPV Follow-up Patient Survey Complete.doc
Cervical Cancer Study: Patient Survey
B12.
B13.
B14.
B15.
B16.
If your health care provider recommends that you
have your next Pap test in 3 years, how likely are
you to wait that long?
How good or bad would it be to wait 3 years for
your next Pap if that is what your health care
provider recommends that you do?
How useless or useful would it be to wait 3 years
for your next Pap?
How comforting or worrying would it be to wait 3
years for your next Pap?
How wise or foolish would it be to wait 3 years for
your next Pap?
Page 7
Very unlikely
Somewhat unlikely
Neither unlikely nor unlikely/not sure
Somewhat likely
Very likely
Very good
Somewhat good
Neither good nor bad
Somewhat bad
Very bad
Very useless
Somewhat useless
Neither useless nor useful
Somewhat useful
Very useful
Very comforting
Somewhat comforting
Neither comforting nor worrying
Somewhat worrying
Very worrying
Very wise
Somewhat wise
Neither wise nor foolish
Somewhat foolish
Very foolish
Thank you very much for filling out this survey.
Please put the survey into the enclosed
postage-paid envelope, and drop it in a mailbox.
G:\Controlled Files\PD\FG601906-01\SAQ-FU\HPV Follow-up Patient Survey Complete.doc
| File Type | application/pdf |
| File Title | Microsoft Word - HPV Follow-up Patient Survey Complete.doc |
| Author | TREECEM |
| File Modified | 2009-01-21 |
| File Created | 2009-01-21 |