Follow-up Patient Survey

Cervical Cancer Study
Patient Survey–Follow-Up

Form Approved

OMB Control No. 0920- 0814

Expiration Date: 06/30/2012

STUDY

LOGO

HERE

Approximately 18 months ago, when you visited the study clinic 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 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.

• The survey should take about 10 minutes to complete.

• Your name is not included on your survey.

• Your answers will be kept private to the extent allowed by law.

• Answers from all women surveyed will be combined.

• Some of the questions are personal but provide important information for this study.

• It is your choice to complete the survey. You may choose to skip any questions that you do not want to answer.

• Only people connected with this survey will see your answers. Your doctor will not see them.

• 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.

Thank you!

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 (0920-0814)

Centers for Public Health Research and Evaluation

1100 Dexter Avenue N., Suite 400

Seattle, Washington 98109-3598

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 () the best answer.
A1.	What is your date of birth?		- MONTH YEAR
A2.	Which type of health insurance do you have? Please  all that apply.		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 the study clinic for your health care in the past 12 months? Do not include visits for friends or family members.		Never 1 time 2-4 times 5-10 times More than 10 times
A4.	Is the study clinic the one you use most of the time when you need to see a doctor?		Yes No
A5.	Have you visited other clinics or doctors’ offices in the past 12 months for your health care?		Yes No
A6.	Approximately 15 months ago you had a Pap test at the study clinic. After that Pap test, when were you told to come back for your next Pap test?		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

A7.	How many times have you had a Pap test in the last 15 months?		None 1 Pap test 2 Pap tests 3 or more Pap tests I’m not sure
A8.	Did you have your most recent Pap test at the study clinic?		Yes No
A9.	How many months ago was your last Pap test?		# of months ago
A10.	What were the results of your last Pap test?		Normal Abnormal I’m not sure I didn’t get any results I was told I would be contacted if there was a problem
A11.	How good or bad did you feel after getting the results of your last Pap test?		Very good Somewhat good Neither good nor bad Somewhat bad Very bad
A12.	How worried or relieved did you feel after getting the results of your last Pap test?		Very worried Somewhat worried Neither worried nor relieved Somewhat relieved Very relieved
A13.	How happy or unhappy did you feel after getting the results of your last Pap test?		Very happy Somewhat happy Neither happy nor unhappy Somewhat unhappy Very unhappy

A14.	After you received the results of your last Pap test, what did your doctor tell you to do? Please  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 15 months, has a doctor or nurse told you that your Pap test was not normal?		Y Go to Question A16. es N o I’m not sure
	A. How many months ago did you have the Pap result that was not normal?		# of months ago
A16.	When do you expect to get your next Pap test? Please  only one answer.		In less than 3 months In 3–6 months In 6–9 months In 9–12 months In more than 12 months I’m not sure

PART B: Your Opinions About HPV and Pap Tests
					Go to Question B2.
B1.	Before today, have you ever heard of HPV? HPV stands for Human Papillomavirus.				Y es N Go to Question B12. o
B2.	Please  all of the sources below where you learned about HPV.
	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:
B3.	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						
					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						
B4.	When you had your last Pap test, did you get an HPV test at the same time?				Yes N Go to Question B5. o I’m not sure
	A. What was the result of your HPV test?				HPV-Positive HPV-Negative I Go to Question B5. ’m not sure
	B. How good or bad did you feel after getting the result of your HPV test?				Very good Somewhat good Neither good nor bad Somewhat bad Very bad
	C. How worried or relieved did you feel after getting the result of your HPV test?				Very worried Somewhat worried Neither worried nor relieved Somewhat relieved Very relieved
	D. How happy or unhappy did you feel after getting the result of your HPV test?				Very happy Somewhat happy Neither happy nor unhappy Somewhat unhappy Very unhappy
B5.	Have you ever been told by a health care provider that you had HPV infection?				Yes No I’m not sure

B6.	Would you want to get an HPV test the next time you get a Pap test?				Yes No I’m not sure
B7.	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?				Very good Somewhat good Neither good nor bad Somewhat bad Very bad
B8.	How useless or useful will it be to get an HPV test next time you get a Pap test?				Very useless Somewhat useless Neither useless nor useful Somewhat useful Very useful
B9.	How comforting or worrying will it be to get an HPV test next time you get a Pap test?				Very comforting Somewhat comforting Neither comforting nor worrying Somewhat worrying Very worrying
B10.	How wise or foolish will it be to get an HPV test next time you get a Pap test?				Very wise Somewhat wise Neither wise nor foolish Somewhat foolish Very foolish
B11.	Please  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								

B12.	If your health care provider recommends that you have your next Pap test in 3 years, how likely are you to wait that long?		Very unlikely Somewhat unlikely Neither unlikely nor unlikely/not sure Somewhat likely Very likely
B13.	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?		Very good Somewhat good Neither good nor bad Somewhat bad Very bad
B14.	How useless or useful would it be to wait 3 years for your next Pap?		Very useless Somewhat useless Neither useless nor useful Somewhat useful Very useful
B15.	How comforting or worrying would it be to wait 3 years for your next Pap?		Very comforting Somewhat comforting Neither comforting nor worrying Somewhat worrying Very worrying
B16.	How wise or foolish would it be to wait 3 years for your next Pap?		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.