Word Version Demographic Screener

Attachment 4B.

Young Sisters Initiative (YSI) Program

Demographic Screener

Form Approved
OMB No: 0920-XXXX
Expiration Date: XX/XX/XXXX

Young Sisters Initiative (YSI) Program

Demographic Screener

Public reporting burden for this collection of information is estimated to average 5 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: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, Mailstop D74, Atlanta, GA 30333; ATTN: PRA 0920-XXXX. Do not return the completed form to this address.

YOUNG SISTERS INITIATIVE PROGRAM

DEMOGRAPHIC SCREENER

Website Welcome language

Welcome and thank you for visiting the Young Sisters Initiative: A Guide to a Better You Program! The YSI program is targeted to African American young breast cancer survivors to provide you with information and resources to help you during your cancer journey. The YSI program provides you with information on coping with fear of recurrence, fertility, and sexual dysfunction); ways to cope with psychosocial and reproductive health issues; and ways to cope with the side effects of breast cancer treatment.

To access the YSI program information you must register for the site. Please complete the brief screener below as part of an evaluation study before registering for YSI program access. The purpose of the screener is to gather your demographic information (such as age, race, and breast cancer diagnosis) so that we can understand who uses the YSI program. The screener should take you less than 5 minutes to complete. Your answers will be maintained in a secure manner and will only be shared with members of the evaluation team. We will not link your responses to any information that identifies you as an individual. Your responses will be used to shape the content and structure of the YSI program to best meet the needs of African American young breast cancer survivors. Your participation is voluntary. By completing the screener, you are agreeing to participate in the evaluation study. Once you have completed the screener, you will be asked to create a username and password that you can use to access the site at your leisure.

If you are already a registered user, click here (allows users to enter username and password and proceed to the YSI web site).

1. How did you hear about the YSI program?

• Friend

• Family member

• Internet

• Radio advertisement

• Newspaper advertisement

• Sisters Network Inc.

• Other (please specify_____)

2. What type of YSI program user are you?

• Breast cancer survivor

• Spouse/family member

• Caregiver

• Health care provider

• Other (please specify_____)

3. What is your current age? _____

4. Are you Hispanic or Latina?

• Yes

• No

5. Which of these groups represents your race? Select one or more.

• Black or African American

• White

• American Indian or Alaska Native

• Asian

• Native Hawaiian or Other Pacific Islander

6. Are you a breast cancer survivor?

• Yes

• No (Skip to website registration)

7. What was the date of your breast cancer diagnosis? _____

8. Were you diagnosed with breast cancer on or before your 45^th birthday?

• Yes

• No

9. What was the stage of your breast cancer at diagnosis?

• Stage I

• Stage II

• Stage III

• Stage IV

• Other (please specify_____)

10. Which of the following statements BEST describes your family structure?

• I have one or more children and plan to have more children in the future (if selected: Number of children __)

• I have one or more children but do NOT plan to have any more children in the future

• I do NOT have any children but plan to have one or more children in the future

• I do NOT have children and do NOT plan to have any children in the future.

• Other (please specify _____)

11. Please describe your treatment history (check all that apply):

• Surgery (if selected: Date of most recent surgery __/__/__)

  • Lumpectomy

  • Mastectomy

• Chemotherapy (if selected: Start date of chemotherapy __/__/__)

• Biologics

  • Herceptin

  • Avastin

• Hormonal therapy (if selected: Start date of hormonal therapy __/__/__)

• Radiation therapy (if selected: Start date of radiation __/__/__)

• Other treatment (please specify_____)

12. Are you willing to participate in a brief survey following your use of the YSI website to tell us about your experience with the YSI program?

• Yes

• No

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