Form 1 Screener & Survey Sub-Study #1

OMB #: 0925-0589-01

Expiry Date: 5/31/2011

Appendix A—Screener

Public reporting burden for this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0589-01, expiration date 5/31/2011). Do not return the completed form to this address.

[Introductory language will be developed in conjunction with NexCura and will be presented to potential participants via an email.]

1. Have you been diagnosed with colon cancer between the years 1999 and 2007?

___ Yes

___ No

2. Have you been diagnosed with prostate cancer between the years 1999 and 2007?

___ Yes

___ No

OMB #: 0925-0589-01

Expiry Date: 5/31/2011

Appendix B—Main Survey

Public reporting burden for this collection of information is estimated to average 18 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0589-01, expiration date 5/31/2011). Do not return the completed form to this address.

Part I.

Think back to when you were first diagnosed with colon/prostate cancer. Remember how you felt and what you were thinking. Now, mark the answer that best matches your thoughts and feelings when you were first diagnosed with cancer, but before you knew much about it.

1. How much did you think having colon/prostate cancer would affect your life?

1 2 3 4 5 6 7 8 9 10

not at all severely

affected affected

2. How long did you think your colon/prostate cancer would continue?

1 2 3 4 5 6 7 8 9 10

a very forever

short time

3. How much control did you feel you would have over your colon/prostate cancer?

1 2 3 4 5 6 7 8 9 10

absolutely an extreme

no control amount of control

4. How much did you think that treatment could help your colon/prostate cancer?

1 2 3 4 5 6 7 8 9 10

not at all extremely helpful

helpful

5. How much did you think you would experience symptoms from your colon/prostate cancer?

1 2 3 4 5 6 7 8 9 10

no symptoms many severe

at all symptoms

6. How concerned were you about your colon/prostate cancer?

1 2 3 4 5 6 7 8 9 10

not at all extremely

concerned concerned

6. How well did you feel you would understand your colon/prostate cancer?

1 2 3 4 5 6 7 8 9 10

don’t understand

understand very clearly

at all

7. How much did you think your colon/prostate cancer would affect you emotionally? For example, does it make you angry, scared, upset or depressed?

1 2 3 4 5 6 7 8 9 10

not at all extremely affected

affected

emotionally

8. Please list from most to least important the three most important factors that you believed caused your colon/prostate cancer. The most important causes for me:

1. __________________________________

2. __________________________________

3. __________________________________

Part II.

Please continue to remember how you felt when your doctor told you that you had colon/prostate cancer. Now, imagine that he or she gave you the information we just showed you. Answer the following questions as though your doctor had given you the survival information we showed you.

If your doctor had given you the survival information we showed you when you were diagnosed with cancer,

1. What would you say the “take-home” message is?

2. How worried would you be about dying of colon/prostate cancer within 5 year(s)?

1 2 3 4 5

not at all an overwhelming amount

worried of worry

3. How worried would you be about dying of some other illness within 5 year(s)?

1 2 3 4 5

not at all an overwhelming amount

worried of worry

4. Would you be more worried about dying of colon/prostate cancer or of something else within 5 year(s)?

____ Colon/prostate cancer

____ Something else

____ Equally worried about both

____ I don’t know

5. Do you think colon/prostate cancer patients can do something to reduce their chances of dying from colon/prostate cancer?

1 2 3 4 5 DK

definitely definitely I don’t

cannot reduce can reduce know

risk risk

6. Do you think colon/prostate cancer patients can do something to reduce their chances of dying from other illnesses?

1 2 3 4 5 DK

definitely definitely I don’t

cannot can reduce know

risk risk

7. How bad would colon cancer be for you?

1 2 3 4 5 DK

not bad extremely I don’t

at all bad know

8. Do you feel that you would die from colon/prostate within 5 year(s)?

1 2 3 4 5 DK

definitely definitely I don’t

not will know

9. Do you feel that you would die from something else within 5 year(s)?

1 2 3 4 5 DK

definitely definitely I don’t

not will know

Part III.

According to the handout…

1. Out of 100 people like this person, how many will survive for 5 year(s)? ________

2. Are people like this more likely to die of colon/prostate cancer or of something else within 5 years?

____ Colon/prostate cancer

____ Something else

____ Equally worried about both

____ I don’t know

3. How believable is the information on this page?

1 2 3 4 5 not

believable completely

at all believable

4. How accurate is the information on this page?

1 2 3 4 5

not

accurate completely

at all accurate

5. How much do you trust the information on this page?

1 2 3 4 5

not

at all completely

Part IV.

Please help us learn more about you.

1. In what year were you diagnosed with cancer? ________

2. Which of the following numbers represents the biggest risk of getting a disease?

____ 1 in 100

____ 1 in 1,000

____ 1 in 10

3. What is your gender?

____ Male

____ Female

4. What is your age? ________

5. What is the last grade you completed?

____ Some high school or less

____ High school graduate

____ Some college or 2-year college degree

____ 4-year college graduate or more

6. How would you describe your ethnicity?

____ Hispanic or Latino

____ Not Hispanic or Latino

7. How would you describe your race?

____ American Indian or Alaska Native

____ Asian

____ Black or African American

____ Native Hawaiian or Other Pacific Islander

____ White

Part V.

Please share any comments or concerns you have about providing this type of information to people who are newly diagnosed with cancer.

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