Form 1 Screener ICD

Concise ICD Study Screener
Invitation to Participate in Study

OMB No. 0925­0046­20,  
Expiry Date 02/28/2013 
Public reporting burden for this collection of information is estimated to average 10 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 (0925­0046­20). Do not return the completed form to this address. 
Welcome and thank you for responding to the invitation to take this survey that is being sponsored by the National Cancer Institute (NCI). NCI wants 
to explore how to best explain a clinical trial in colorectal cancer to future patients. We will be asking your opinions about one document that 
describes this clinical trial.  

The survey is not recruiting you to participate in an actual trial or testing your knowledge about clinical trials. It is to help make sure information 
about a specific clinical trial is clear and understandable. Some of the questions at the beginning of the survey are about your personal experience 
with cancer. Your responses will be kept secure to the extent provided by law and not shared with others. 

1. Would you like to continue with the survey?

j Yes
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j No
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Introductory Questions

We need to ask you a few questions to determine whether you are eligible to participate in the survey and also to help us 
ask you the right questions.  

Your time and opinions are greatly valued. 

2. What is your age?
j Less than 18 (Disqualifited)
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j 18 or older
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3. Have you ever been diagnosed with cancer?

j Yes
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j No (Disqualified)
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Concise ICD Study Screener
4. With what type of cancer have you ever diagnosed? (Check all that apply.)
j None (Disqualified)
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j Colorectal cancer only
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j Colorectal cancer and other type(s) of cancer
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j Cancer type(s) other than colorectal cancer (Disqualified)
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5. Are you currently in treatment for cancer?
j Yes (Disqualified)
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j No
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6. How long ago were you diagnosed with colorectal cancer?
j Within the last 10 years
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j More than 10 years ago (Disqualified)
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7. Have you completed treatment for your colorectal cancer?

j Yes
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j No (Disqualified)
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8. What type of treatment did you receive for your colorectal cancer?

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Concise ICD Study Screener
9. What stage of colorectal cancer were you diagnosed with?
j Stage 1
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j Stage 2
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j Stage 3
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j Stage 4
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j I wasn’t told
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j I don’t know
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10. Did they tell you the colorectal cancer had metastasized (that is, it spread to other
organs)?

j Yes
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j No
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11. Have you ever taken part in a clinical trial?
j Yes (Disqualified)
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j No
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12. Are you, or is anyone in your household, employed in any of the following fields or
areas? (Check all that apply.)
c The medical field, medical research (Disqualified)
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c Market research, media or advertising (Disqualified)
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c The pharmaceutical or healthcare industry (Disqualified)
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c Any part of the Federal government (Disqualified)
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c No one in my household is employed by these groups
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13. Do you work for the American Cancer Society or a similar organization that focuses on
cancer, or does your work involve people with cancer or their families?
j Yes (Disqualified)
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j No
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Concise ICD Study Screener
14. How confident are you in filling out medical forms by yourself?
j Extremely confident
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j Quite a bit
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j Somewhat
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j A little bit
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j Not at all (Disqualified)
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15. Are you comfortable reading, reviewing, and discussing materials in English?

j Yes
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j No (Disqualified)
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You have qualified to participate in the study

Thanks! You’ve qualified to participate in this study.  

To begin, please answer the brief set of questions that follow. After, [INSERT VENDOR NAME FOR PANEL] will then 
mail you a document to review. Once you get it, please review it and log back into this survey and we’ll ask you the 
remaining questions about it. Thank you again. Your feedback will help the National Cancer Institute explain clinical trials 
to future patients with cancer. 

Most important, there are no right or wrong answers—so don’t think this is a test. The first few questions ask you about 
clinical trials overall. 

16. This question is about knowledge about clinical trials.
I DID NOT 

I knew A LOT 

know anything 

about clinical 

about clinical 

trials

trials
Before today, what best describes your level of knowledge about clinical 

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trials?

17. This question is about taking part in cancer clinical trials.
NOT AT ALL 

VERY likely

likely
If you were diagnosed with cancer again, how likely is it that you would 

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consider participating in a clinical trial and it was offered to you?

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Concise ICD Study Screener
18. The following statements describe attitudes about participating in cancer clinical trials.
Please read each statement and circle how much you agree with each statement, using a
scale of “1” through “6,” where “1” means Strongly Disagree and “6” means Strongly
Agree.
Strongly 

Strongly 

Disagree

Agree

N/A

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Being in a clinical trial is a way for me to help others.

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I would receive better health care if I participated in a 

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Other people will benefit from the clinical trial results if I 
participate in a clinical trial.

clinical trial.
My health would be followed more closely if I were in a 
clinical trial.
Being in a clinical trial would give me the best and newest 
treatments.
Being in a clinical trial could give me a better chance of 
being cured.
If I heard of a new medical test or treatment, I would try to 
find out more about it.
Among my friends, I am usually one of the first to find out 
about a new medical test or treatment.
In general, I am hesitant to undergo a new medical test or 
treatment

Thank You

Thank you for your participation. Please click the link below to submit your responses. [Vendor name] will mail you the 
document to review and instructions for next steps. We thank you again for your support of this study! 

19. Click the button to submit
j Submit survey
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j Do not submit survey
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Thank You for Your Help

This completes the introductory survey. Thank you very much for your time and opinions.  

SPECIFIC INSTRUCTIONS FROM THE PANEL PROVIDER WILL BE ADDED WITH REGARDS TO INCENTIVES, ETC. 

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