Changes to Att 4b - Patient Post-Intervention Survey

Form Approved

OMB Control No: 0920-0769

Expiration Date: 03/31/2011

Patient Post-Intervention Survey

Clinical Care and Health Survey:

Patient Opinions

Screening and Prevention Survey

Funded by

The Centers for Disease Control and Prevention

Atlanta, GA

We are interested in your your opinions and experiences you’ve had when talking with your doctor or health care provider talking about colon cancer screening. Even if you have not talked to your doctor or provider about colon cancer screening, or even if you have not been screened, please still fill out this survey. This may have included a talk about colon cancer screening tests. We would like to know how you feel about talking with your clinician about these issues. Your Your opinions are important to us!

Filling in Completing this survey will help us design make programs to help your clinician provider and others give better patient care. You may be contacted one more time in the future so that we can learn more about the opinions and experiences you’ve have talking to your doctor about colon cancer. You may have received a similar survey about colon cancer screening in the past. Please complete this new survey whether or not you filled out a similar one a few months ago.

 You were selected to receive this survey because you are age patients 50 years old and or older who are active members and you visited an [HMO] clinic in the past 3 months of [this HMO] are being sent this survey. You are being paid $10 to compensate you for your time and effort.

 Your answers are strictly private

 Your name is not included Please do not put your name on your survey

 Answers from other patients like you will be combined into one final summary

 Some questions are personal, but provide important information for this study

 It is your choice to skip any questions that you do not want to answer

 Your doctor will not see your answers

 Filling in this survey can only improve patient care

We thank you very much for taking your time to fill in this survey for us.

When you are done, please mail it back to us in the enclosed envelope.

 Please also mail your signed HIPPA form which allows us to include your survey answers in our final summary [ABQ HP/Lovelace participants only]

CDC LOGO Thank you!

[Logo Deleted]

Centers for Public Health Research and Evaluation

1100 Dexter Avenue N., Suite 400 Seattle WA 98109

This survey has several ways it asks questions that come in different forms. When any question asks about “your clinician provider”, it means the doctor or medical practitioner who last gave you a routine check-up provides your routine primary care. You will need to write in or check () what you think is the best answer. Please see examples below.

Some questions look like this:

A1. What is your age? _________________

A2. Are you male or female? 1 Male 2 Female?  Male

 Female

You will need to write in your age or check () the answer the box for male or female.

Some questions ask you to rate your feelings. Please think about how you feel about each of the topics.

For example, the questions look like this:

A3. How satisfied were you with…..
Neither
Very Satisfied Nor Very

Dissatisfied Dissatisfied Dissatisfied Satisfied Satisfied

a. the doctor’s explanation of the      

screening procedure

Please check () the answer that best shows how you feel.

Some questions ask you to give us your opinions. Please think about if you disagree or agree about each of the statements that you read.

For example, the questions look like this:

Neither
Strongly Agree nor Strongly

Disagree Disagree Disagree Agree Agree

c. Men get colon cancer more often than      

Women

Please check () the answer that best shows how strongly you disagree or agree with the statement.

Patient Questionnaire

Part I SECTION A: Tell Us About Yourself

This section asks questions to let us describe patients who take part in the survey. Please answer the following questions. Please write in or check () the best answer.

A1. What is your age? ____________

A2. What is your sex?  Male

 Female

A3. Do you consider yourself: (Select Please  only one)

 Hispanic or Latino

 Not Hispanic or Latino

A4. What is your race? (please  one or more)

 White

 Black or African American

 Asian

 American Indian or Alaska Native

 Native Hawaiian or Other Pacific Islander

A5. What language do you usually speak at home?

 English  Spanish  Other (Please specify) ___________________

A6. What is the highest grade or year of school you finished? (formerly was #8)

 Didn’t go to school

 Grade School (1-5 years)

 Middle school (6-8 years)

 Some High School (9-11 years)

 High school diploma or G.E.D.

 Vocational or training school

 Some college or Associate Arts Degree

 College graduate with BA or BS Degree

 Graduate/professional education and/or Degree

A7. Are you employed?  Yes (If Yes, please answer Question A7a)

 No (If No, please go to Question A8)

If Yes: A7a: Are you employed full time or part time: Is it  Full Time

 Part Time

A8. What was your total family income (before taxes) from ALL income sources in your household in the last year? (Please check () the one that is your best guess).

 Less than $10,000

 $10,000 to $19,000

 $20,000 to $34,000

 $35,000 to $49,000

 $50,000 to $74,000

 $75,000 +

 Don’t know

Now we would like to ask you about your relationship with your doctor. Please write in or check () the best answer. If a question asks about “this doctor”, it means the doctor or clinician who gave you your annual check-up (i.e., annual exam, yearly physical exam).

Next are some questions about the primary care provider you mostg recently saw.

A9. How long have you been a patient with the doctor who did your last annual check-up the primary care provider you most recently saw? _________ Years _______Months

A10. How would you describe How often you have seen this doctor provider?

(Please check  all that apply).

 I am a new patient of this doctor provider and I have only visited once or twice.

 I get most of my care from this doctor provider.

 This doctor provider does most of my annual check-ups.

 I get most of my care from another doctor or nurse provider in this doctor’s the same office.

 I get most of my care from another doctor’s or nurse’s provider’soffice.

 Other (Please specify) _________________________________

11. How many times in the past year have you seen this doctor? ____________

12. Which type of health coverage do you have in your health plan? (Check () all that apply)

 Co-pay less than or equal to $10 for all clinic visits

 Co-pay between $10 and $20 for all clinic visits

 Free (no cost) annual exam visit

 Co-pay for annual exam visit

 Free (no cost) preventive services (screening for cholesterol, blood sugar, cervical cancer, colorectal cancer, breast cancer, prostate cancer)

 Co-pay for all preventive services (screening for cholesterol, blood sugar, cervical cancer, colorectal cancer, breast cancer, prostate)

Part II: Personal Cancer Experience and
Family History of Colon Cancer

Please answer the following questions about colon cancer. When we use the term colon cancer, we mean cancer of the colon, rectum, or bowel. You may also have heard the term colorectal cancer. Please write in or check () the best answer.

1. How likely do you think you are to develop colon cancer sometime in your life?

Would you say it is…

 Extremely unlikely  Unlikely  Neither likely or unlikely  Likely  Extremely likely

2. Compared to other people your age how would you rate your own risk of getting colon cancer?

 Much lower  Lower  About the same  Higher  Much higher

3. In general, would you say that your health is….

 Excellent  Very good  Good  Fair  Poor

4. Have you ever been diagnosed with cancer?

 Yes  No (go to question 5)

If ‘Yes’, what type of cancer? __________________________________

5. Has anyone in your immediate family (i.e., spouse, children, parents, siblings) ever been diagnosed with cancer?

 Yes  No or Don’t Know (Go to Part III, Question 1)

If ‘Yes’, please list your immediate family members who have had cancer and the type of cancer. List up to 5 family members.

Family Member	Type of Cancer
1._________________________	_________________________
2._________________________	_________________________
3._________________________	_________________________
4._________________________	_________________________
5._________________________	_________________________

Part III SECTION B: Experience with Tests and Screenings

Now we are interested in your experience with colorectal cancer screening or testing talking with your primary care provider about disease prevention and having different screening tests, including colon cancer screening. When we use the term colon cancer, we mean cancer of the colon, rectum or bowel. It is sometimes called colorectal cancer. Please answer the following questions. about colon cancer and colon cancer screening tests.

B1. Have you ever had any bowel symptoms (i.e., blood in the stool, changes in bowel movements) that prompted caused your doctor provider to suggest you be tested for colon cancer?

 Yes  No

[Now question # 3)

B2. Have you heard of the following tests for colon cancer?

	Yes	No
a. Digital rectal exam Rectal exam “finger test”		
b. Fecal occult blood test (FOBT) or Hemoccult test (stool card test)		
c. Fecal Immunochemical Test (FIT) d. Flexible sigmoidoscopy	 	 
e. Colonoscopy		
f. Virtual colonoscopy g. Barium enema	 	 

[Now question #4]

B3. How worthwhile do you think the following tests are for detecting colon cancer early?

(Please mark “Don’t Know” if you have never heard of the test)

	Not at all worthwhile	Slightly worthwhile	Somewhat worthwhile	Quite worthwhile	Very worthwhile	Don’ t Know
a. Digital rectal exam Rectal exam “finger test”						
b. Fecal occult blood test (FOBT) or Hemoccult (stool card test)						
c. Fecal Immunochemical Test (FIT) d. Flexible sigmoidoscopy	 	 	 	 	 	 
e. Colonoscopy						
f. Virtual colonoscopy g. Barium enema	 	 	 	 	 	 

[Now question #5)

B4. Please check () below if your doctor primary care provider did or ordered the following tests at your last check-up AND / OR some other time in the last five years.
Tests ordered Did your provider order aby of the following tests?:	Done or Ordered at last Check-up Visit?  answer		Done or Ordered in the last 5 years?  answer
	Yes	No	Yes	No
a. Blood pressure check				
b. Cholesterol test (blood test)				
c. Digital Rectal exam for colon cancer (i.e., ‘finger’ test)				
d. FOBT (stool card test)				
e. Flexible sigmoidoscopy				
f. Colonoscopy				
For Women:
g. Pap smear				
h. Breast exam				
i. Mammogram (breast x-ray)				
For Men:
j. Prostate specific antigen blood test (PSA)				

[Now question #2)

B5. Please check () below if your doctor provider talked to you about each issue at your last check-up AND / OR anytime in the last five years.
Did your doctor provider talk to you about:	Talked about at last check-up?			Talked about in the last 5 years?			IF TALKED ABOUT: Who brought the subject up?
	Yes	No	NA	Yes	No	NA	Me	Doctor	NA
a. Smoking									
b. Exercise or physical activity									
c. Your dietary practices Dietary and nutritional habits									
d. Colon cancer screening									
For Women: e. Breast Cancer Screening f. Cervical cancer screening	 	 	 	 	 				
For Men: Prostate cancer screening									
Colorectal cancer screening									
Fecal occult blood test (FOBT)									
Flexible sigmoidoscopy									
Colonoscopy									

[now question #1)

Section C: Personal Cancer Experience and Family History of Colon Cancer

Please answer the following questions about colon cancer. To answer the following questions, please write in or check () the best answer.

C1. In general, would you say that your health is….

 Excellent

 Very good

 Good

 Fair

 Poor

C2. Have you ever been diagnosed with cancer?  Yes (if Yes, please answer Question C2a)

 No (If No, please answer Question C3)

C2a. What type of cancer? (Please specify): __________________________________

_______________________________________________________________________

C3. Has anyone in your immediate family (i.e., spouse, children, parents, siblings) ever been diagnosed with cancer?

 Yes

 No

 Don’t Know

C4. Has anyone in your immediate family (i.e., spouse, children, parents, siblings) ever been diagnosed with colon cancer?

 Yes

 No

 Don’t Know

C5. How likely do you think you are to develop colon cancer sometime in your life? Would you say it is:

 Extremely unlikely

 Unlikely

 Neither likely or unlikely

 Likely

 Extremely likely

C6. Compared to other people your age how would you rate your own risk of getting colon cancer?

 Much lower

 Lower

 About the same

 Higher

 Much higher

Part IV SECTION D: Colon Cancer Screening Experience

Now we are interested in your experience with either FOBT, Flexible Sigmoidoscopy or Colonoscopy, and barium enema.

FOBT stands for a Fecal Occult Blood Test which is a set of cards to take home to collect 3 stool samples. Then you mail in or return the cards to be tested for hidden blood in the stool. (Sometimes called Hemoccult test or stool card test).

Flexible Sigmoidoscopy is also called a ‘Flex Sig’. It is when a doctor or nurse practitioner inserts a flexible tube into your rectum (or bottom) to check for bowel problems and colon cancer. You have a preparation that you do at home, The Flex Sig is done in a clinis without a sedative. You have to have someone to drive you home, and you may have to miss work for the day.

A Colonoscopy is a medical procedure which you will have is done in a clinic or hospital setting. It allows a full viewing of the colon. You will have a preparation that you will do at home, and during the procedure you will be are given a sedative. A doctor inserts a flexible tube into your rectum (or bottom) to check for bowel problems and colon cancer. You have to have someone drive you home, and you may have to miss work for the day.

D1.	Where have you received information about colon cancer screening tests? Please check () all that apply.	Yes	No
	a. Brochure in the clinic		
	b. Your provider		
	c. Nurse or medical assistant		
	d. Work wellness program		
	e. Information packet mailed to you		
	f. Media (TV, magazines, radio, etc.)		
	g. Friends or family		
	h. Other (Specify: __________________________)		

D2. Please check whether and when you have had each of the following colon cancer screening tests. (Please check () only one box for each test).

	Never had screening	Less than 6 months ago	6 months to a year ago	1-2 years ago	3-5 years ago	6-10 years ago	More than 10 years ago
a. FOBT							
b. Flexible Sigmoidoscopy							
c. Colonoscopy							
d. Barium Enema							

Fecal Occult Blood Test (FOBT)

2. Have you been given an FOBT kit to take home in the last year?

 Yes  No (If No, go to Question 9)

3. Were you given instructions on how to use the FOBT cards?

 Yes  No

4. Were you reminded to return the cards?

 Yes  No

5. Did you return the cards?

 Yes  No If No, Why not? _____________________________________

6. Did you get the results?  Yes  No

7. How did you get the results?

Phone call from:  physician  nurse  medical assistant

Letter from:  physician  clinic  lab

8. Please check () the best answer below:
How satisfied were you with…..	Very Dissatisfied	Dissatisfied	Neither Satisfied nor Dissatisfied	Satisfied	Very Satisfied
a. Colon cancer information given by your doctor’s office					
b. The doctor’s explanation of the procedures to do the FOBT test					
c. Dietary restrictions					
d. Overall preparations for the FOBT					
e. Collection of the stool sample					
f. Reminder procedures					
g. Follow-up procedures					
h. Explanation of the FOBT test results					
i. Receiving the FOBT test results					

Flexible Sigmoidoscopy (Flex Sig) (Please see the definition on page 6)

9. In the past 5 years did your doctor recommend a Flex Sig test?

 Yes  No (If No, go to Question 14)

10. Did you schedule an appointment?

 Yes  No If No, Why not? _________________________________________

11. Did you have the test?

 Yes  No If No, Why not? _________________________________________

12. Did you get the results?  Yes  No

13. Please check () the best answer below:
Flex Sig How satisfied were you with…..	Very Dissatisfied	Dissatisfied	Neither Satisfied nor Dissatisfied	Satisfied	Very Satisfied
a. Colon cancer information given by your doctor					
b. The doctor’s explanation of the Flex Sig screening test					
c. Dietary restrictions					
d. The use of an enema or laxatives					
e. Overall preparations for the Flex Sig					
f. The convenience of the screening location					
g. How the screening technician treated me					
h. The level of discomfort during the Flex Sig procedure					
i. Follow-up procedures					
j. Explanation of the Flex Sig test results					

Colonoscopy (Please see the definition on page 6)

14. In the past 10 years did your doctor recommend a Colonoscopy test?

 Yes  No (If No, skip to next section)

15. Did you schedule an appointment?

 Yes  No If No, Why not? _________________________________________

16. Did you have the test?

 Yes  No If No, Why not? _________________________________________

17. Did you get the results?  Yes  No

18. Please check () the best answer below:
How satisfied were you with…..	Very Dissatisfied	Dissatisfied	Neither Satisfied nor Dissatisfied	Satisfied	Very Satisfied
a. Colon cancer information given by your doctor					
b. The doctor’s explanation of the Colonoscopy screening test					
c. Dietary restrictions					
d. The use of an enema or laxatives					
e. Overall preparations for the Colonoscopy					
f. The convenience of the screening location					
g. How the screening technician treated me					
h. The level of discomfort during the Colonoscopy procedure					
i. Follow-up procedures					

NOTE: Following questions D3 through D8 related to patient's experience with CRC screening at his/her last PC visit, are old (modified) questions, which in the original survey were in Part IX. In the new survey the whole part IX is deleted (see above), and these few questions have been moved to this section. Number of items and information to be gathered remains the same, with no impact on purpose, scope or anticipated analyses.

Now we are interested in your experience with colon cancer screening at your last primary care visit and in the past few years.

D3. Did you receive any information about colorectal cancer screening in the mail, before your last primary care visit?

 Yes (Continue)

 No (If No, go to Question D6)

D4. Did you read through the information about colorectal cancer screening before your appointment?

 Yes

 No

D5.

Did you find the information about colon cancer screening to be helpful?

Yes No

D6. Did you and your provider talk about colon cancer screening at your last primary care visit?

• Yes (Continue)

 No (If No, please go to Question D9)

• Yes (Continue)

No (If No, please go to Question D9)

D7. Who started the conversation about colon cancer screening at your last primary care visit? Please  only one.

 You

 Your provider

 One of clinic staff

D8. Please check how strongly you agree or disagree with the statements about your colon cancer screening discussion at your last primary care visit.

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. I felt that colon cancer screening was important for me.					
b. My provider listened carefully to what I had to say about colon cancer screening.					
c. My provider answered all my questions about colon cancer screening.					
d. I felt that colon screening could prevent colorectal cancer.					
e. I felt understood					
f. I felt comfortable expressing my feelings about colon cancer screening					
g. My provider acted like I was wasting his or her time.					
h. I felt comfortable asking questions about colon cancer screening					
i. I felt pressured to get screened					
j. I wanted the conversation to end					
k. At the end of the discussion I wanted to get screened for colon cancer					

Fecal Occult Blood Test (FOBT) (Please see the description on page X.)

D9.	At your last primary care visit, did your provider talk with you about colon cancer screening with an FOBT kit?		Yes (Continue) No (If No, please go to Question D12)
D10.	At your last primary care visit, did your provider recommend that you get screened with an FOBT kit?		Yes (Continue) No (If No, please go to Question D12)
D11.	At your last primary care visit, were you given an FOBT kit to take home?		Yes (If Yes, please go to Question D13) No (Continue)

.

D12. In the last year, were you given an FOBT kit to take home?

 Yes (Continue)

 No (If No, go to Question D20)

D13. When you were given the kit, did someone at your provider’s office give you instructions on how to use the FOBT cards?

 Yes

 No

D14. After you got home, did someone from your provider’s office remind you to return the cards?

 Yes

 No

D16. Did you return the FOBT cards?

 Yes (Continue)

 No (If No, please go to Question D20) _____________________________________

D17. How did you get the results?

 Phone call from the provider’s office

Letter from the provider’s office

In person

Never go the results

D15. How satisfied were you with…..	Very Dissatisfied	Dissatisfied	Neither Satisfied nor Dissatisfied	Satisfied	Very Satisfied
a. Colon cancer information given by your provider’s office					
b. The provider’s explanation of the procedures to do the FOBT test					
c. The instructions on how to do the FOBT					
d. Getting help from your clinic if you had questions about completing the FOBT kit					
D18. How satisfied were you with (Please check the best answer)	Very Dissatisfied	Dissatisfied	Neither Satisfied nor Dissatisfied	Satisfied	Very Satisfied
a. Dietary restrictions					
b. Overall preparations for the FOBT					
c. Completing the FOBT kit at home					
d. Collection of the stool sample					
e. Sending the sample to the clinic or lab					
f. The clinic or lab contacting you about your FOBT rest results					
g. Explanation of the FOBT test results					

D19.	What motivated you to get screened with the FOBT? Please check () all that apply.	Yes	No
	a. Talking with your provider		
	b. Nurse or medical assistant		
	c. Reading about colon cancer screening		
	d. Friends or family members		
	e. Colon cancer screening materials received in the mail		
	f. Hearing about colon cancer screening in the media		
	g. Work wellness program		
	h. Other (Specify: __________________________)		

Flexible Sigmoidoscopy (Flex Sig) (Please see the description on page X.)

D20.	At your last primary care visit, did your provider talk with you about Flex Sig screening?		Yes (Continue) No (If No, please go to Question D22)
D21.	At your last primary care visit, did your provider recommend Flex Sig screening?		Yes (If Yes, please go to Question D23) No (Continue)

. D22. In the past 5 years did your doctor recommend a Flex Sig screening?

 Yes (Continue)

 No (If No, go to Question D25)

D23. Did you schedule a Flex Sig appointment?

 Yes (Continue)

 No (If No, go to Question D25)__

D24.. Did you have the screening?

 Yes

 No

Colonoscopy (Please see the description on page 5)

D25.	At your last primary care visit, did your provider talk with you about Colonoscopy screening?		Yes (Continue) No (If No, please go to Question D27)
D26.	At your last primary care visit, did your provider recommend Colonoscopy screening?		Yes (If Yes, please go to Question D28) No (Continue)

D27. In the past 10 years did your provider recommend a Colonoscopy screening?

 Yes (Continue)

 No (If No, please go to section E)__

D29. Did you or someone at the clinic schedule a Colonoscopy appointment for you?

 Yes (Continue)

 No (If No, please go to section E)_

D30.

Did you receive a call or mail to remind you to keep your Colonoscopy appointment?

Yes No

D31 Did you have the screening?

• Yes (Continue)

• No, I am still scheduled (If No, please go to Section E)

No, I decided not to have it (If No, please go to Section E)

D32. How did you get the results?

• Phone call from the provider’s office

• Letter from the provider’s office

• In person

Never got the results

D28. When your provider recommended the Colonoscopy, how satisfied were you with…..	Very Dissatisfied	Dissatisfied	Neither Satisfied nor Dissatisfied	Satisfied	Very Satisfied
a. Colon cancer information given by your provider’s office					
b. Your provider’s explanation of the Colonoscopy screening					

D33.	When you had the Colonoscopy, how satisfied were you with:	Very Dissatisfied	Dissatisfied	Neither Satisfied nor Dissatisfied	Satisfied	Very Satisfied
	a. The process of making the Colonoscopy appointment					
	b. The time interval between making the appointment and the actual screening appointment					
	c. Dietary restrictions for the Colonoscopy					
	d. Getting help from your clinic if you had questions about colonoscopy					
	e. The use of laxative or enema					
	f. Overall preparations for the Colonoscopy					
	g. The convenience of the screening location					
	h. How the screening specialist treated you					
	i. Your comfort during the Colonoscopy procedure					
	j. The doctor or clinic contacting you about your Colonoscopy test results					
	k. Explanation of the Colonoscopy test results					

D34.	What motivated you to get screened by Colonoscopy? Please check () all that apply.	Yes	No
	a. Talking with your provider		
	b. Nurse or medical assistant		
	c. Reading about colon cancer screening		
	d. Friends or family members		
	e. Colon cancer screening materials received in the mail		
	f. Hearing about colon cancer screening in the media		
	g. Work wellness program		
	h. Other (Specify: __________________________)		

Part V SECTION E: Your Opinions About Colon Cancer Knowledge

E1. For each of the following statements please check if you “disagree”, “agree” or are “not sure”.

	Disagree	Agree	Not Sure
a. Eating foods high in fat increases your risk of developing colon cancer.			
b. Your chances of getting colon cancer are greater if you have a family member who had colon cancer.			
c. Men get colon cancer more often than women.			
d. If a person gets colon cancer, it cannot be cured.			
e. Blood in your stool means you have cancer for sure.			
f. A diet with a lot of roughage fiber, like fruits, vegetables, and grains, may reduce your chances of getting colon cancer.			
g. You should have your stool tested for hidden blood every year if you are 50 years or older. If you have colon cancer, you would have symptoms.			

Part VI SECTION F: Your Opinions About Colon Cancer Screening

Please check () how strongly you disagree or agree with each opinion below.

F1. Discussing colon cancer screening with my doctor provider:

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. is not necessary because of my age.					
b. is hard to do because my doctor doesn’t think it is important.					
c. is not as important as talking about other health problems I have.					
d. is only needed if I have symptoms.					
e. would just mean that I would have to have more unnecessary tests done.					
f. is not needed because my doctor has already covered all the issues with me.					
g. would take too much time.					
h. would make me uncomfortable.					
i. is something the doctor won’t talk about because my insurance doesn’t cover it.					
i. is hard to do because my doctor is not easy to talk to.					
j. is a waste of time because when I ask questions, the doctor doesn’t have answers.					
k. would be embarrassing.					

Whether or not you have been given an FOBT kit to take home, your opinions are important to us.

Please check () how strongly you disagree or agree with each opinion below about FOBT (Stool CARDS).

F2. Having an FOBT (Fecal Occult Blood Test):

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. is needed only if I have symptoms.					
b. is needed only if there is a family history of colon cancer.					
c. is not needed if I eat a healthy diet.					
d. would only detect cancer after it is too late.					
e. would give me a feeling of control over my health.					
f. is something I am too busy to do.					
g. would protect my health so I can take better care of my family.					
h. is not as important as screening tests for other diseases and cancers.					
i. is something I am sure I can do					
j. is not necessary at my age.					
k. would be awful (disgusting) because I have to handle my stool.					
l. is a test I like being able to do in the privacy of my own home.					
m. is not needed if I’ve had it once before.					
n. involves too much hassle because I have to prepare for the test.					
o. is something I don’t know how to do correctly.					
p. is a waste of time because the test is not accurate.					
q. is unnecessary for women because only men are at risk for colon cancer					
r. would make me worry about the results					
s. is unnecessary if I have a Flex Sig or a Colonoscopy					

Whether or not you have had a Flex Sig, your opinions are important to us.

Please check () how strongly you disagree or agree with each opinion below.

3. Having a Flex Sig (Flexible Sigmoidoscopy) test:

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. is needed only if there is a family history of colon cancer					
b. can prevent me from getting colon cancer by finding and removing polyps that could become cancer					
c. is unnecessary if I have an FOBT					
d. is unnecessary if I have a Colonoscopy					
e. is not needed if I eat a healthy diet					
f. would only detect cancer after it is too late					
g. would give me a feeling of control over my health					
h. is something I am too busy to do					
i. would protect my health so I can take better care of family					
j. is not as important as screening tests for other diseases and cancers					
k. is a hassle because the wait for the appointment is too long					
l. is not necessary at my age					
m. would be embarrassing					
n. would be stressful (frightening, scary)					
o. would be uncomfortable					
p. is not needed if I’ve had it once before					
q. involves too much hassle because I have to prepare for the test					
r. is unnecessary for women because only men are at risk for colon cancer					

Whether or not you have had a Colonoscopy, your opinions are important to us.

Please check () how strongly you disagree or agree with each opinion below about colonoscopy.

F3. Having a Colonoscopy screening test:

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. is needed only if there is a family history of colon cancer					
b. can prevent me from getting colon cancer by finding and removing polyps that could become cancer					
c. is unnecessary if I have an FOBT					
d. is unnecessary if I have a Flex Sig					
e. is not needed if I eat a healthy diet					
f. would only detect cancer after it is too late					
g. would give me a feeling of control over my health					
h. is something I am too busy to do.					
i. is something I am sure I can do					
j. would protect my health so I can take better care of family					
k. is not as important as screening tests for other diseases and cancers					
l. is a hassle because the wait for the appointment is too long					
m. is not necessary at my age					
n. would be embarrassing					
o. would be scary					
p. would be uncomfortable					
q. is not needed if I have had it once before					
r. involves too much hassle because I have to prepare for the test					
s. is unnecessary for women because only men are at risk for colon cancer					
t. would make me worry about the results					
u. is hard because I would have to go to another clinic for the test					

Whether or not you have been given an FOBT kit to take home or had a Flex sig or Colonoscopy screening, your opinions are important to us.

5. Please check () how strongly you disagree or agree with each opinion below:

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. Fitting a flex sig screening test into my schedule is hard					
b. I have trouble taking time off from work to do the flex sig test					
a. Fitting a colonoscopy screening test into my schedule is hard					
b. I have trouble taking time off from work or changing my schedule to do the colonoscopy test					
c. Colon cancer screening is a way for doctors and insurers to make money					
f. Medicare pays for flex sig screening					
g. Medicare pays for colonoscopy screening					
h. My insurance or health plan pays for flex sig screening					
i. My insurance or health plan pays for colonoscopy screening					
d. I would do the FOBT kit if my doctor provider tells me to					
e. I would do the flex sig screening if my doctor provider tells me to					
f. I would do the colonoscopy screening if my doctor tells me to					
g. My doctor never provider always talks about screening for colon cancer					
h. My doctor never provider always talks about FOBT					
o. My doctor never talks about flex sig					
i. My doctor never talks always talks about colonoscopy					

Part VII SECTION G: Social Support

Please check () how strongly you disagree or agree with each opinion below.

G1. Discussing colorectal cancer screening with my doctor (the one who did my last check-up) is something that is encouraged by:
	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. my spouse or partner  NA					
b. my family					
c. my friends					
d. my doctor provider or nurse					
e. the popular media (TV, radio, magazines)					

G2. My having an FOBT is something that is encouraged by:
	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree		Strongly Agree
a. my spouse or partner  NA					
b. my family					
c. my friends					
d. my doctor provider or nurse					
e. the popular media (TV, radio, magazines)					

3. My having a screening flex sig is something that is encouraged by:
	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree		Strongly Agree
a. my spouse or partner					
b. my family					
c. my friends					
d. my doctor or nurse					
e. the popular media (TV, radio, magazines)					

G3. My having a screening colonoscopy screening is something that is encouraged by:
	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree		Strongly Agree
a. my spouse or partner  NA					
b. my family					
c. my friends					
d. my doctor provider or nurse					
e. the popular media (TV, radio, magazines)					

Part VIII SECTION H: Plans to Talk About Colon Cancer or Get Screened

Please check () how strongly you disagree or agree with each opinion below.

H1. Please answer the following questions about cancer screening:
	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. I plan to discuss colon cancer screening with my doctor provider at my next check-up primary care visit.					
b. I plan to get screened for colon cancer in the next year. c. I plan to do an FOBT after my next check-up for colon cancer screening in the next year.					
d. I plan to have a Flexible Sigmoidoscopy after my next check-up for colon cancer screening in the next year.					
I plan have a Colonoscopy after my next check-up for colon cancer screening in the next year. I plan to do whatever my doctor tells me to do for colon cancer screening in the next year.	 	 	 	 	 

Part IX: Colon Cancer Screening at Last Check-Up

1. Please check () if you or your doctor did the following things at your last check-up.

	Yes	No
a. Did you receive any information about colorectal cancer screening in the mail, before your appointment?		
b. If Yes: Did you read through the information about colorectal cancer screening before your appointment?		
c. Did you bring up colorectal cancer screening with your doctor?		
d. Did your doctor bring up colorectal cancer screening with you?		
e. Did any clinic staff (medical assistant, nurse) discuss colorectal cancer screening with you?		

If your doctor did not talk to you about colon cancer screening at your last check-up, please skip to the end.

2. Please check () how strongly you agree or disagree with the statements about your colorectal cancer screening discussion at your last check-up.

Check-up and colorectal cancer screening experience:	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. The doctor or other clinic staff made me feel that colorectal cancer screening was important for me.					
b. The doctor or other clinic staff listened carefully to what I had to say.					
c. The doctor or other clinic staff answered all my questions.					
d. The doctor or other clinic staff made me feel that screening could prevent colorectal cancer.					
e. I trust that the doctor and other clinic staff have my best interest at heart.					
f. The doctor and other clinic staff act like I’m wasting their time.					
g. The doctor and other clinic staff treat me in a very friendly and courteous manner.					

3. Please check () if you or your doctor did the following things at your last check-up.

	Yes	No
a. Did your doctor discuss colorectal cancer screening with an FOBT kit with you?		
b. Did your doctor recommend that you should do your colorectal cancer screening with an FOBT kit?		
c. Did you agree that you should do your colorectal cancer screening with an FOBT kit?		
d. Did you get an FOBT home kit from your doctor or other clinic staff?		
e. Did you phone the consulting nurse to ask questions about the FOBT home kit after your appointment?		
f. Did you receive a phone call from a nurse or medical assistant after your appointment to ask about your FOBT home kit?		
g. Did you return your FOBT cards to your doctor’s office?		

If you did not get an FOBT home kit during your last check-up, please skip to question 6.

4. Please check () how satisfied you were with your FOBT colon cancer screening experience from your last check-up.

FOBT experience:	Very Dissatisfied	Somewhat Dissatisfied	Neither	Somewhat Satisfied	Very Satisfied
a. The way the doctor explained the need for the FOBT test.					
b. The way the doctor or clinic staff explained how to do the FOBT test.					
c. The interaction you had with the doctor during your visit.					
d. The interaction you had with other clinic staff during your visit.					
e. Your check-up in general					
f. The process of completing the FOBT kit at home.					
g. How easy it was to return the completed kit.					
h. The written instructions on how to complete your FOBT kit at home.					
i. The help you received from the consulting nurse if you called her.					
j. The help you received from the nurse or medical assistant if s/he called you.					

5. Please check () how strongly you agree or disagree with the statements describing your colorectal cancer screening experience with the FOBT kit you got at your last check-up.

FOBT experience:	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. The diet restrictions of the FOBT were easy to follow.					
c. Completing the FOBT kit at home was easy.					
d. The directions for completing the FOBT kit were easy to understand.					
e. I knew who I could call if I had questions about completing the FOBT kit at home.					
f. Waiting for the test results made me worry.					

6. Please check () if you or your doctor did the following things at your last check-up.

	Yes	No
a. Did your doctor discuss a screening flex sig with you?		
b. Did any clinic staff (medical assistant, nurse) discuss a screening flex sig with you		
c. Did your doctor recommend that you should do your colorectal cancer screening with a flex sig?		
d. Did you agree that you should do your colorectal cancer screening with a flex sig?		
e. Did you schedule for a flex sig appointment?		
If Yes:
f. Did you receive a phone call or post card to remind you to keep your appointment for the flex sig?		
g. Did you keep your flex sig appointment?		
h. Are you still waiting for your flex sig appointment?		

If you did not discuss Flex Sig for Colon Screening during your last check-up, please skip to question 9.

7. Please check () how satisfied you were with discussing flex sig during your last check-up.

Flex sig discussion:	Very Dissatisfied	Somewhat Dissatisfied	Neither	Somewhat Satisfied	Very Satisfied
a. The way the doctor explained the need for the flex sig test.					
b. The way the doctor explained how the flex sig was done.					
c. The interaction you had with the doctor about flex sig.					
d. The interaction you had with other staff about flex sig.					
f. The process of making the appointment for the flex sig.					
h. The written instructions on how to prepare for the appointment.
i. The way the doctor explained the dietary restrictions.					

If you have not yet had your Flex Sig screening appointment, please skip to question 9.

8. Please check () how strongly you agree or disagree with the statements describing your flex sig experience.

Flex Sig experience:	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. The dietary restrictions to prepare for the flex sig were easy to follow.					
b. It was hard to wait for the appointment.					
c. The staff at the flex sig appointment were helpful.					
d. Waiting for the test results made me worry.					
e. I knew who I could call if I had questions about the flex sig appointment.					
f. Keeping the appointment was easy.					

9. Please check () if you or your doctor did the following things at your last check-up.

	Yes	No
a. Did your doctor discuss a screening colonoscopy with you?		
b. Did any clinic staff (medical assistant, nurse) discuss a screening colonoscopy with you		
c. Did your doctor recommend that you should do your colorectal cancer screening with a colonoscopy?		
d. Did you agree that you should do your colorectal cancer screening with a colonoscopy?		
e. Did you schedule for a colonoscopy appointment?		
If Yes:
f. Did you receive a phone call or post card to remind you to keep your appointment for the colonoscopy?		
g. Did you keep your colonoscopy appointment?		
h. Are you still waiting for your colonoscopy appointment?		

If you did not discuss Colonoscopy for Colon Screening during your last check-up, please skip to the end.

10. Please check () how satisfied you were with your colonoscopy screening experience.

	Very Dissatisfied	Somewhat Dissatisfied	Neither	Somewhat Satisfied	Very Satisfied
a. The way the doctor explained the need for the colonoscopy test.					
b. The way the doctor explained how the colonoscopy was done.					
c. The interaction you had with the doctor about colonoscopy.					
d. The interaction you had with other staff about colonoscopy.					
f. The process of making the appointment for the colonoscopy.					
h. The written instructions on how to prepare for the appointment.
i. The way the doctor explained the dietary restrictions.					

11. Please check () how strongly you agree or disagree with the statements describing your colonoscopy experience.

If you have not yet had your Colonoscopy screening appointment, please skip to the end.

Colonoscopy experience:	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree
a. The dietary restrictions to prepare for the colonoscopy were easy to follow.					
b. It was hard to wait for the appointment.					
c. The staff at the colonoscopy appointment were helpful.					
d. Waiting for the test results made me worry.					
e. I knew who I could call if I had questions about the colonoscopy appointment.					
f. Keeping the appointment was easy.					

Please let us know if you have any additional comments:

The End

Thank you very much for completing your THIS survey

Please place it in the enclosed, stamped, envelope [,along with your signed HIPPA authorization form ABQ AP/Lovelace onl] and drop it in the mail for us!

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