Word Version - Post-Use Survey

Attachment 5B.

Young Sisters Initiative (YSI) Program

Post-Use Survey

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

Young Sisters Initiative (YSI) Program

Post-Use Survey

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: 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

POST-USE SURVEY

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.

You previously agreed to complete a brief survey after accessing the YSI program. The following survey asks you a series of questions about your experiences with the YSI program.

1. What type of YSI program user are you?

• Breast cancer survivor

• Spouse/family member

• Caregiver

• Health care provider

• Other (please specify_____)

2. What is your current age? _____

3. Are you Hispanic or Latina?

• Yes

• No

4. 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

5. Are you a breast cancer survivor?

• Yes

• No

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

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

• Yes

• No

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

• Stage I

• Stage II

• Stage III

• Stage IV

• Other (please specify_____)

9. What are your overall general thoughts about the YSI program?

[Text box response]

10. On a scale of 1-5, how easy was it to access the YSI program?

1. Very difficult to access

2. Difficult to access

3. Neutral

4. Easy to access

5. Very easy to access

11. What helped you be able to access the YSI program?

[Text box response]

12. What were the barriers to your access the YSI program?

[Text box response]

13. On a scale of 1-5, how easy was it to navigate the YSI program?

1. Very difficult to navigate

2. Somewhat difficult to navigate

3. Neutral

4. Easy to navigate

5. Very easy to navigate

14. What helped you be able to navigate the YSI program?

[Text box response]

15. What were the barriers to your navigating the YSI program?

[Text box response]

16. On a scale of 1-5, how easy was it to follow the structure of the YSI web site?

1. Very difficult to follow

2. Somewhat difficult to follow

3. Neutral

4. Easy to follow

5. Very easy to follow

17. What are your overall thoughts about YSI program content?

[Text box response]

18. On a scale of 1-5, how useful was the YSI content?

1. Very unuseful

2. Somewhat unuseful

3. Neutral

4. Somehwat useful

5. Very useful

19. How the YSI program was content useful to you on the YSI program web site?

[Text box response]

20. On a scale of 1-5, how helpful are the resources on the YSI program web site? (e.g., on the Other Resources Page)?

1. Very unhelpful

2. Somewhat unhelpful

3. Neutral

4. Somewhat helpful

5. Very helpful

21. On a scale of 1-5, how satisfied were you with the YSI program?

1. Very unsatisfied

2. Somewhat unsatified

3. Neutral

4. Somewhat satisfied

5. Very satisfied

22. What is the most helpful information you encountered on the YSI program website?

• About Us information [skips to question 24]

• Word animation video [skips to question 24]

• YSI Program Workbook

• Resources [skips to question 24]

• Survivor videos [skips to question 24]

• Contact Us form [skips to question 24]

23. Which section of the YSI Program workbook was most helpful to you?

• Section 1: Breast Cancer, Treatment, and Aftercare

• Section 2: Breast Cancer Risk and Your Family

• Section 3: Emotional Health and Wellness

• Section 4: Living with Breast Cancer: Family, Friends, and Workplace Issues

• Section 5: Premature Menopause and Breast Cancer

• Section 6: Health and Beauty

• Section 7: Breast Cancer, Sexuality, and Dating

• Section 8: Fertility, Pregnancy, and Motherhood After Breast Cancer

24. What is the least helpful information you encountered on the YSI program website?

• About Us information [skips to question 26]

• Word animation video [skips to question 26]

• YSI Program Workbook

• Resources [skips to question 26]

• Survivor videos [skips to question 26]

• Contact Us form [skips to question 26]

25. Which section of the YSI Program workbook was most helpful to you?

• Section 1: Breast Cancer, Treatment, and Aftercare

• Section 2: Breast Cancer Risk and Your Family

• Section 3: Emotional Health and Wellness

• Section 4: Living with Breast Cancer: Family, Friends, and Workplace Issues

• Section 5: Premature Menopause and Breast Cancer

• Section 6: Health and Beauty

• Section 7: Breast Cancer, Sexuality, and Dating

• Section 8: Fertility, Pregnancy, and Motherhood After Breast Cancer

26. On a scale of 1-5, how likely are you to return to the YSI program for information and/or support?

1. Very unlikely

2. Somewhat unlikely

3. Neutral

4. Somewhat likely

5. Very likely

27. On a scale of 1-5, how likely are you to recommend the YSI program to others?

1. Very unlikely

2. Somewhat unlikely

3. Neutral

4. Somewhat likely

5. Very likely

Thank you for completing this survey.

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