Form 1 Facilitator Conducted Survey

OMB No.: 0925-0642

Expiration Date: 9/30/2014

Public reporting burden for this collection of information is estimated to average 20 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 (0925-0642). Do not return the completed form to this address.

Global Cancer Research Satisfaction Questionnaire

Attachment 1: Global Cancer Research Satisfaction Questionnaire

Demographic Information.

ID Number Age: Gender:

Position/Title:

1. Educational Status:

• High School or Less

• Up to Bachelors Degree

• Nursing Degree or Diploma

• Masters Degree

• Doctorate

• MBBS/MD

2. Was all your education in full or part completed in the (check all that apply)

• North America region?

• African region?

• Asian region?

• European region?

• Latin American region?

3. Did you leave the region to pursue your higher degree/s Yes No

• If yes, where did you go?

Other regional country UK France USA Other

Institutional Information. In this section, please tell us about your institution.

1. How would you describe your institution? Mark all that apply

• A primary health center ( mainly outpatient)

• A hospital ( primarily inpatient and referral center)

• A medical college

• A research center

• Other (please specify)

• All of the above

2. Does your institution have or have access to cancer diagnostics facilities? Yes No

If yes, please check what facilities are available (Mark all that apply)

• Laboratory

• Pathology

• Imaging Facility

• Chemotherapy

• Radiation

• Surgery

• Palliative Care

• Consultant ENT

• Counseling Care and Support

• Nutrition Services

• Pharmacy

3. For the facilities that you have/have access to, please describe in your own words what works well and how, if at all, you want to improve them? For example you could say that in your laboratory, diagnoses are accurate and staff are well trained. But you need more staff and equipment to improve services.

• Laboratory

• Pathology

• Imaging facility

• Chemotherapy

• Radiation

• Surgery

• Palliative Care

• Consultant ENT

• Counseling, Care and Support

• Nutrition Services

• Pharmacy

4. For the facilities that you do not have/have access to, please describe how far the nearest facility is from your institution and how you interact with this facility. Please share any needs and concerns, as well as ideas you have to get these facilities in your institutions.

• Laboratory

• Pathology

• Imaging facility

• Chemotherapy

• Radiation

• Surgery

• Palliative Care

• Consultant ENT

• Counseling, Care and Support

• Nutrition Services

• Pharmacy

5. How many patients are seen at your institution per day?

5a. Inpatient ____________________

5b. Outpatient __________________

6. Does your institution provide transportation for patients? Yes No

7. Does your institution have a community education/outreach program? Yes No

8. Does the institution have capacity to avail of telemedicine facilities? Yes No

9. How long does a patient have to typically wait to see a doctor? (Circle which applies)

1 hour or less 1-2 hours

2-4 hours >4 hours

Your Affiliation with your Institution. Please tell me about your experiences with this institution?

1. How long have you been with your current institution? (Circle which applies)

Less than 1 year 1-4years >=5years

2. Are you involved in any of these programs relating to cancer control in your institution? (check all that apply)

• Education Programs

• Health Care Delivery

• Research

• Staff Training

• Program Development ( grant writing, securing funds)

• Other (Specify ____________________________)

3. If you need training or information about cancer care and management, please indicate what is available to you at your institution

• Consult a colleague

• Consult a mentor

• CME programs are available through my institution

• Other, specify ____________________________

4. How many times have you participated in a seminar or CME relating to cancer care and management in the past 2 years in your institution?

• Never

• 0 times

• Once

• Two or more

5. Are there programs to sponsor training in cancer care and management at your institution?

Yes No

Needs for Cancer Research: Cancer Burden.

1. What are the top three cancers in your country

For each cancer, please answer the following:

1. Is the incidence rising? Yes No

2. If yes, is this based on data or on personal impression?

Data – please state

Personal Impression – Please clarify _______________________________________________________________

3. What are the risk factors that you see for (this) cancers? (Check all that apply)

• Tobacco Use

• Occupational Exposure

• Alcohol Use

• Poor Diet

• Lack of Physical Activity

• Lack of Information about cancer preventionLack of Information about cancer screening

• Poor health care facilities

• Poor access to health care facilities for cancer

• Poor follow-up upon screening

• Poor follow-up post screening to treatment

• Other, please specify ___________________________

4. Are these the same for men and women? Yes No

If No, please clarify?

5. At what age group for men do you see the most new cases?

6. At what age group for women do you see the most new cases?

2. For Head and Neck Cancers,

1. What is the primary site of head and neck cancers?

2. What is the proportion in the oropharynx?

3. Is there an increased proportion of head and neck cancers in patients who have never smoked?

4. Do these patients have HIV?

5. Do you test for HPV?

6. At what stage are these cancers typically diagnosed?

7. What treatment modalities are available/used?

8. Are there guidelines for provision of palliative care?

Cancer Research Needs: Need for Information.

1. If a patient wants to learn cancer, what are some channels of information that exist currently? (Check all that apply)

• Public awareness program

• Radio programs

• TV posts and public service announcements

• NGO campaigns

• Internet

• Other

• Nothing exists in my area

2. What are some needs with regard to community education about cancer?

3. Are there any existing support groups for cancer? If so, please describe them ( what cancer cancer type focus, how do they initiate interaction with patients, and health system)

4. What are some needs associated with stigma reduction in cancer?

Cancer Research Needs: Cancer Research Capacity.

1. Based on your experience, what are some research questions in cancer that need to be addressed? Please list them.

2. Do you have a registry for cancers in your institution or in your region?

Yes No

2a. If yes, describe the data collection process (active vs. passive)

3. Are there any active research studies ongoing in your institution?

Yes No

3a. If yes, please describe the study/ies

4. How many medical colleges are there in your country?

5. To your knowledge, does the medical curriculum include training in research methods?

Yes No

6. How many public health colleges are there in your country?

7. How many nursing colleges are there in your country?

Thank you for providing feedback that will improve support and services delivered by the Center for Global Health at the National Cancer Institute.

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