Form 1 CIS Survey

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Block 1 Introduction
Instructions

You recently called the National Cancer Institute's Cancer Information Service (CIS) and
talked about clinical trials with a Cancer Information Specialist.

Please respond to the following questions related to this conversation.

OMB# 0925-0046-XX
Exp. Date: xx/xx/2016

Public reporting burden for this collection of information is estimated to average 60 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 (0925-0046-13).  Do not
return the completed form to this address.

Thank you for participating in this survey.
Block 2 Questions
Do you recall discussing clinical trials with a CIS Information Specialist?
Yes
No

What type of information did you receive about clinical trials? (choose all that apply)
NCI publications or other printed materials
PDQ clinical trials search results
PDQ cancer site-specific summary

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Other

Were you calling for yourself or were you calling for someone else?
Myself
Someone else

Was the information about clinical trials appropriate to your (or your loved one's) situation or
condition?
Yes
No

How was the information inappropriate?

How did you receive the clinical trials information? (check all that apply)
Phone
Mail
E-mail
LiveHelp
Other

How useful was the clinical trials information you received by PHONE?
Not at all Useful
Not Very Useful
Somewhat Useful
Very Useful
Extremely Useful

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How useful was the clinical trials information you received by MAIL?
Not at all Useful
Not Very Useful
Somewhat Useful
Very Useful
Extremely Useful

How useful was the clinical trials information you received by E-MAIL?
Not at all Useful
Not Very Useful
Somewhat Useful
Very Useful
Extremely Useful

How useful was the clinical trials information you received by LiveHelp?
Not at all Useful
Not Very Useful
Somewhat Useful
Very Useful
Extremely Useful

How useful was the clinical trials information you received by your OTHER option?
Not at all Useful
Not Very Useful
Somewhat Useful
Very Useful
Extremely Useful

Did your conversation with the CIS Information Specialist give you a better understanding of
clinical trials?
Yes
Somewhat
No

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How did you (or your loved one) use the information you received by phone or in print?
(choose all that apply)
Read the information
Discussed the information with doctor/s
Discussed the information with family members/friends
Looked for more information about a clinical trial on the internet
Other (please specify)

How helpful was the information in preparing you for a discussion with a doctor?
Not at all Helpful
A Little Helpful
Somewhat Helpful
Very Helpful
Extremely Helpful

Did the doctor discuss the information with you/your loved one?
Yes
No

To what extent did the doctor's response meet your/your loved one's expectations?
Fell far short of expectations
Fell short of expectations
Equaled expectations
Exceeded expectations
Far exceeded expectations

What additional resources might have been helpful for your discussion with a doctor? (choose
all that apply)
No additional resources were needed
A booklet on the basics of clinical trials
Specific questions to ask your doctor to see if the clinical trial is right for you
Information on the benefits of participating in a trial
Information on steps taken to assure protection of patients participating in trials
Information about informed consent
Other (please specify)

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Did the doctor discuss clinical trials as a possble treatment option for you/your loved one?
Yes
No

Did the doctor make a referral to a specific clinical trial?
Yes
No

Have you/your loved one considered enrolling in a clinical trial?
Yes
No

Did you/your loved one contact a clinical trial representative about a specific clinical trials?
Yes
No

Have you/your loved one enrolled in a clinical trial?
Yes
No, but plan to do so
No

Did the information provided by the CIS Information Specialist influence the decision to
participate in a clinical trial?
Yes
Somewhat
No

How did the information provided to you by the CIS Information Specialist influence your
decision?

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What could have been done to make the service you received more useful for you/your loved
one?

Would you call the CIS again if you needed information about cancer and cancer treatment?
Yes
Maybe
No

Block 3 Submit
If you have completed the survey, click the SUBMIT button.

YOU MUST HIT THE SUBMIT BUTTON FOR YOUR RATINGS TO BE SUBMITTED!

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