Colorectal Cancer Population Survey

I am going to read some statements. Please answer whether you “strongly agree” “somewhat agree”, “neither agree nor disagree”, “somewhat disagree”, or “strongly disagree” with each statement.

Section A: Colorectal cancer screening ATTITUDES AND PERCEPTIONS

/ [BASE: All respondents]

CRCSATT1 Getting tested for colorectal cancer is embarrassing.

Would you say you…

READ LIST

01 Strongly agree

02 Somewhat agree

03 Neither agree nor disagree

04 Somewhat disagree

05 Strongly disagree

97 - Don’t know

99 - refused

CRCSATT2 Getting tested for colorectal cancer takes too much time.

CRCSATT3 Getting tested for colorectal cancer is reassuring.

CRCSATT4 Getting tested for colorectal cancer will help me avoid having a more serious cancer.

CRCSATT5. There are so many different colorectal cancer screening tests that it's hard to know which one to use.

//TO BE DISPLAYED on CRCSATT2-CRCSATT5//

[INTERVIEWER: READ IF NECESSARY: Would you say you…]01 Strongly agree

02 Somewhat agree

03 Neither agree nor disagree

04 Somewhat disagree

05 Strongly disagree

97 - Don’t know

99 - refused

SECTION B: Colorectal cancer screening Knowledge

/ [BASE: All respondents]

NORMTEST. If a colorectal cancer screening test comes out normal, you do not need to be tested again.

ASYMTEST. You don’t need to have a colorectal cancer screening test until you have some symptoms.

[INTERVIEWER: READ IF NECESSARY: Would you say you … ]

01 Strongly agree

02 Somewhat agree

03 Neither agree nor disagree

04 Somewhat disagree

05 Strongly disagree

97 - Don’t know

99 - refused

SECTION c: RESPONSE EFFICACY

/ [BASE: All respondents]

RESPEFF. Colorectal cancer screening tests are effective in finding cancer.

[INTERVIEWER: READ IF NECESSARY: Would you say you … ]

01 Strongly agree

02 Somewhat agree

03 Neither agree nor disagree

04 Somewhat disagree

05 Strongly disagree

97 - Don’t know

99 - REFUSED

SECTION D: SOCIAL SUPPORT AND SOCIAL INFLUENCES

/ [BASE: All respondents]

SOCSUP. Some members of my family or my friends think I should have colorectal cancer screening tests.

[INTERVIEWER: READ IF NECESSARY: Would you say you … ]

01 Strongly agree

02 Somewhat agree

03 Neither agree nor disagree

04 Somewhat disagree

05 Strongly disagree

97 - Don’t know

99 - REFUSED

SECTION e: CANCER WORRY AND ANXIETY

[BASE: All respondents]

WORRY1. I am worried that if I get tested for colorectal cancer, I might find out that I have cancer.

WORRY2. I am worried about getting tested for colorectal cancer because I do not understand what the test will involve.

[INTERVIEWER: READ IF NECESSARY: Would you say you … ]

01 Strongly agree

02 Somewhat agree

03 Neither agree nor disagree

04 Somewhat disagree

05 Strongly disagree

97 - Don’t know

99 - REFUSED

SECTION f: PERCEIVED BARRIERS TO SCREENING

[BASE: All respondents]

CRCSBAR People may have different reasons for not getting tested for colorectal cancer. Even people who have been tested may have had reasons why they did not want to have the tests or did not get screened earlier.

How much would you agree or disagree that the following reasons would make it difficult for you to have colorectal cancer screening? Please tell me whether you “strongly agree” “somewhat agree”, “neither agree nor disagree”, “somewhat disagree”, or “strongly disagree” with each statement”.

[BASE: All respondents]

CCSBAR01. The test is too embarrassing

CCSBAR02. The test costs too much

CCSBAR03. My insurance company does not cover all of the costs of the test

CCSBAR04. I cannot afford to pay for the office visit or copay

CCSBAR05. I have other medical problems that are more important than colorectal cancer screening

CCSBAR06. No one in my family has had colorectal cancer

CCSBAR07. I am afraid of having the test

CCSBAR08. I do not know where to get the test done

CCSBAR09. My doctor or health care provider has never suggested I get tested for colorectal cancer

CCSBAR10. I do not need to be tested because I feel fine

CCSBAR11. I do not know if I should be tested for colorectal cancer

01 Strongly agree

02 Somewhat agree

03 Neither agree nor disagree

04 Somewhat disagree

05 Strongly disagree

97 - Don’t know

99 - refused

[BASE: All respondents]

PREQ2. Colonoscopy (colon-OS-copy) and sigmoidoscopy (sigmoid-OS-copy) are exams in which a doctor inserts a tube into the rectum to look for polyps or cancer. For a colonoscopy, the doctor checks the entire colon, and you are given medication through a needle in your arm to make you sleepy, and told to have someone drive you home. For a sigmoidoscopy, the doctor checks only part of the colon and you are fully awake.

[BASE: All respondents]

COLAWR. Before today, had you ever heard of colonoscopy?

01 yes

02 no

97 don’t know

99 refused

[BASE: All respondents]

SIGAWR. Before today, had you ever heard of sigmoidoscopy?

01 yes

02 no

97 don’t know

99 refused

[BASE: All respondents]

How much would you agree or disagree that the following reasons would make it difficult for you to have a sigmoidoscopy or a colonoscopy?

COLBAR01. I do not want to do the preparation and take laxatives

COLBAR02. I am worried that this test is uncomfortable or painful

COLBAR03. I would need to take unpaid time off work to have this test

COLBAR04. It would be hard to get someone to stay with me and take me home after this test

01 Strongly agree

02 Somewhat agree

03 Neither agree nor disagree

04 Somewhat disagree

05 Strongly disagree

97 - Don’t know

99 - REFUSED

[BASE: All respondents]

PREQ3. A home blood stool test is a test to determine whether you have blood in your stool or bowel movement. The blood stool test is done at home using a kit. You use a stick or brush to obtain a small amount of stool at home and send it back to the doctor or lab.

[BASE: All respondents]

OBTAWR. Before today, had you ever heard of the home blood stool or occult blood test?

01 yes

02 no

97 don’t know

99 refused

[BASE: All respondents]

How much would you agree or disagree that the following reasons would make it difficult for you to complete a home blood stool test.

FBTBAR01. I do not want to handle my stool

FBTBAR02. I do not want to keep my stools on a card or in a tube in the house

FBTBAR03. I do not know how to do this test

01 Strongly agree

02 Somewhat agree

03 Neither agree nor disagree

04 Somewhat disagree

05 Strongly disagree

97 - Don’t know

99 - REFUSED

SECTION g: MEDICAL MISTRUST

[BASE: All respondents]

These next set of questions ask about your opinion of your health care system.

By Health Care System I mean: hospitals, community clinics, labs and insurance companies as well as people who are a part of your health care such as doctors, nurses, specialists, x-ray technicians, or office staff.

Please answer whether you “strongly agree”, “somewhat agree”, “neither agree nor disagree”, “somewhat disagree”, or “strongly disagree” with each statement.

[BASE: All respondents]

MEDMIS01. My Health Care System does its best to make patients feel better.

MEDMIS02. My Health Care System makes too many mistakes.

MEDMIS03. My Health Care System puts making money above patient’s needs.

MEDMIS04. Patients get the same medical treatment from my Health Care System, no matter what the patient’s race or, ethnicity.

01 Strongly agree

02 Somewhat agree

03 Neither agree nor disagree

04 Somewhat disagree

05 Strongly disagree

97 - Don’t know

99 - REFUSED

Section h: COLORECTAL CANCER SCREENING KNOWLEDGE of test frequency

[BASE: All respondents]
range=0-95

CRCKAGE. At what age do you think most people are supposed to start colorectal cancer screening?

[IF R SAYS “When a doctor says to,” PROBE FOR “Their best guess”]

enter response

96=96 or more

97 - Don’t know

99 - refused

[BASE: All respondents]

HBSTFREQ. A home blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. You send your stool sample to the doctor’s office or lab for testingOnce people start having home blood stool tests, how often do you think they are supposed to do the test?

[IF R SAYS “When a doctor says to or doctor recommends it,” PROBE FOR “Their best guess of how often according to time”]

[IF R SAYS “It depends on what you find out after your first test” RESPOND with “Assume an individual who is not at increased risk and all previous test results are normal”]

01 Respondent provided answer

97 - Don’t know

99 – REFUSED

/base: if HBSTFREQ=01/

HBSTRESP.

Enter response

–

/base: if HBSTFREQ=97/

HBSTPROB. Please provide your best guess about how often people are supposed to do home blood stool tests once they start having them. Would you say:

01 More than once a year

02 Once a year

03 Once every two years

04 Once every three or four years

05 Once every five to nine years

06 Once every ten years

97 - Don’t know

99 – REFUSED

[BASE: All respondents]

COLFREQ. Colonoscopy (colon-OS-copy) is an exam in which a doctor inserts a tube into the rectum to look for polyps or cancer.

Once people start having colonoscopy exams, how often do you think they are supposed to do the test?

[IF R SAYS “When a doctor says to or doctor recommends it,” PROBE FOR “Their best guess of how often according to time”]

[IF R SAYS “It depends on what you find out after your first test” RESPOND with “Assume an individual who is not at increased risk and all previous test results are normal”]

01 Respondent provided answer

97 - Don’t know

99 – REFUSED

/base: if COLFREQ=01/

COLRESP.

Enter response

/base: if COLFREQ=97/

COLPROB. Please provide your best guess about how often people are supposed to have colonoscopy exams once they start having them. Would you say:

01 More than once a year

02 Once a year

03 Once every two years

04 Once every three or four years

05 Once every five to nine years

06 Once every ten years

97 - Don’t know

99 – REFUSED

SECTION I: SELF-EFFICACY

[BASE: All respondents]

PREQ4. These next questions ask about how confident you feel about getting tested for colorectal cancer. Please answer whether you are “very sure” “somewhat sure”, “neither sure nor unsure”, “somewhat unsure”, or “very unsure”.

[BASE: All respondents]

SELFEFF1. How sure are you that you can discuss getting tested for colorectal cancer with your health care provider even if he or she does not bring it up?

SELFEFF2. How sure are you that you can prepare for and complete the colorectal cancer screening test?

[IF R SAYS “Which type of screening test should I think about?” RESPOND WITH “Consider whichever test you think you would receive”]

SELFEFF3. How sure are you that you would get a colorectal cancer screening test even if a friend or family member told you not to?

01 VERY SURE

02 SOMEWHAT SURE

03 NEITHER SURE NOR UNSURE

04 SOMEWHAT UNSURE

05 VERY UNSURE

97 - Don’t know

99 - REFUSED

SECTION J: COLORECTAL CANCER SCREENING BEHAVIORS

HADCOLT1

These next few questions are about some different screening tests that you may have had to look for signs of colorectal cancer.

IF (COLAWR=1) or (SIGAWR=1)

HADCOLT2

Colonoscopy (colon-OS-copy) and sigmoidoscopy (sigmoid-OS-copy) are exams in which a doctor inserts a tube into the rectum to look for polyps or cancer. For a colonoscopy, the doctor checks the entire colon, and you are given medication through a needle in your arm to make you sleepy, and told to have someone drive you home. For a sigmoidoscopy, the doctor checks only part of the colon and you are fully awake.

HADCOL. Have you had either of these exams?

01 yes

02 no

97 don’t know

99 refused

if HADCOL IN (1)

COLTYPE. Was your most recent exam a sigmoidoscopy or a colonoscopy? __________

[IF NECESSARY: If you were fully awake during the procedure, it was probably a sigmoidoscopy.]

01 Colonoscopy

02 Sigmoidoscopy

97 - Don’t know

99 - REFUSED

if HADCOL IN (1)

COLWHEN. How long has it been since you had your last //insert response to COLTYPE: sigmoidoscopy or colonoscopy//?

[READ IF NECESSARY]

01 Within the past year (anytime less than 12 months ago)

02 Within the past 2 years (1 year but less than 2 years ago)

03 Within the past 3 years (2 years but less than 3 years ago)

04 Within the past 5 years (3 years but less than 5 years ago)

05 Within the past 10 years (5 years but less than 10 years ago)

06 10 or more years ago

97 - Don’t know

99 - refused

if HADCOL IN (1)
mul=8

COLWHY. Please tell me all of the reasons why you had this sigmoidoscopy or colonoscopy – was it…… ?

[READ LIST, SELECT ALL THAT APPLY]

CLWHY_01 Because your doctor or health care provider recommended it

CLWHY_02 Part of a routine exam

CLWHY_03 Because of a problem

CLWHY_04 Follow-up test of an earlier test or screening exam

CLWHY_05 Because you read, saw or heard something about colorectal cancer screening

CLWHY_06 Because you received a reminder to be screened for colorectal cancer by your doctor or health care provider

CLWHY_07 Because your family or friends got tested or told you to get tested for colorectal cancer

CLWHY_08 Some other reason?

97 - Don’t know

99 - refused

if colwhy=8

COLWHYO. For what other reason did you have this sigmoidoscopy or colonoscopy?

enter other response

[BASE: All respondents]

CT colonography, sometimes called virtual colonoscopy, is a new type of test that looks for cancer in the colon. Unlike regular colonoscopies, you do not need medication to make you sleepy during the test. In this new test, your colon is filled with air and you are moved through a donut-shaped X-ray machine as you lie on your back and then your stomach.

[READ IF NECESSARY: This is not the same as a colonoscopy or a sigmoidoscopy. Unlike CT tests for other purposes, you DO take laxatives to clean out your colon for this test.]

[BASE: All respondents]

CTAWR. Before today, had you ever heard of CT colonography or virtual colonoscopy?

01 yes

02 no

97 don’t know

99 refused

IF CTAWR=1

HADCT. Have you ever had a CT colonography or virtual colonoscopy?

01 yes

02 no

97 don’t know

99 refused

IF HADCT=1

CTWHEN. How long has it been since you had your last CT colonography or virtual colonoscopy?

[READ IF NECESSARY]

01 Within the past year (anytime less than 12 months ago)

02 Within the past 2 years (1 year but less than 2 years ago)

03 Within the past 3 years (2 years but less than 3 years ago)

04 Within the past 5 years (3 years but less than 5 years ago)

05 Within the past 10 years (5 years but less than 10 years ago)

06 10 or more years ago

97 - Don’t know

99 - REFUSED

IF HADCT=1
mul=8

CTWHY. Please tell me all of the reasons why you had this CT colonography or virtual colonoscopy - was it …..?

[READ LIST, SELECT ALL THAT APPLY]

CTWHY01 Because your doctor or health care provider recommended it

CTWHY02 Part of a routine exam

CTWHY03 Because of a problem

CTWHY04 Follow-up test of an earlier test or screening exam

CTWHY05 Because you read, saw or heard something about colorectal cancer screening

CTWHY06 Because you received a reminder to be screened for colorectal cancer by your doctor or health care provider

CTWHY07 Because your family or friends got tested or told you to get tested for colorectal cancer

CTWHY08 Some other reason?

97 - Don’t know

99 - Refused

if CTwhy08=01

CTWHYO. For what other reason did you have this CT colonography or virtual colonoscopy?

enter other response

IF OBTAWR=1

The following questions are about the HOME BLOOD STOOL or OCCULT BLOOD TEST, a test to determine whether you have blood in your stool or bowel movement. The blood stool test can be done at home using a kit. You use a stick or brush to obtain a small amount of stool at home and send it back to the doctor or lab.

HADOBT. Have you ever had this test using a home kit?

01 yes

02 no

97 don’t know

99 refused

IF HADOBT=1

OBTWHEN. How long has it been since you had your last blood stool test using a home kit? ________

[READ IF NECESSARY]

01 Within the past year (anytime less than 12 months ago)

02 Within the past 2 years (1 year but less than 2 years ago)

03 Within the past 3 years (2 years but less than 3 years ago)

04 Within the past 5 years (3 years but less than 5 years ago)

05 Within the past 10 years (5 years but less than 10 years ago)

06 10 or more years ago

97 - Don’t know

99 - REFUSED

IF HADOBT=1
mul=8

OBTWHY. Please tell me all of the reasons why you had this home blood stool test - was it…..?

[READ LIST, SELECT ALL THAT APPLY]

OBTWHY01 Because your doctor or health care provider recommended it

OBTWHY02 Part of a routine exam

OBTWHY03 Because of a problem

OBTWHY04 Follow-up test of an earlier test or screening exam

OBTWHY05 Because you read, saw or heard something about colorectal cancer screening

OBTWHY06 Because you received a reminder to be screened for colorectal cancer by your doctor or health care provider

OBTWHY07 Because your family or friends got tested or told you to get tested for colorectal cancer

OBTWHY08 Some other reason?

97 - Don’t know

99 - Refused

if obtwhy08=01

OBTWHYO. For what other reason did you have this home blood stool test?

enter other response

[ASK IF OBTAWR=1]

OBTNC. Have you ever been given a home blood stool test kit that you did not complete and return to the doctor or laboratory?

01 yes

02 no

97 don’t know

99 refused

[ASK IF OBTAWR=1]

OBTOFF. Have you ever had a blood stool test in which your doctor or other health professional collected a stool sample during an office visit?

01 yes

02 no

97 don’t know

99 refused

SECTION k: COLORECTAL CANCER SCREENING RECOMMENDATIONS

if (COLAWR IN (2,97,99) OR SIGAWR IN (2,97,99) OR hadcol in (2,97,99)) and (CTawr in (2,97,99) or hadct in (2,97,99)) and (OBTAWR IN (2,97,99) OR haDobt in (2,97,99) then nevertested=1
if ((coltype=1 and colwhen=6) or (coltype=2 and colwhen in (5,6)) and ctwhen in (5,6) or obtwhen in (2,3,4,5,6)) then distanttest=1
ask if nevertested=1 or distanttest=1

DREC12. In the PAST 12 MONTHS, did a doctor or other health care provider recommend that you be tested to look for problems in your colon or rectum?

01 yes

02 no

97 don’t know

99 refused

IF DREC12=2

DRECEV. Has a doctor or other health care provider EVER recommended that you be tested to look for problems in your colon or rectum?

01 yes

02 no

97 don’t know

99 refused

IF DREC12=1 OR DRECEV=1

DRECTST. Did the doctor or health care provider recommend to you any particular tests?

01 yes

02 no

97 don’t know

99 refused

IF DRECTST=1
mul=6

DRECTYP. Which tests to check for colon cancer did the doctor or health care provider recommend to you?

[READ LIST, SELECT ALL THAT APPLY]

RCTYP_01 Home blood stool test (INTERVIEWER: READ IF NECESSARY: also referred to as fecal occult blood test)

RCTYP_02 Sigmoidoscopy

RCTYP_03 Colonoscopy

RCTYP_04 Virtual colonoscopy

RCTYP_05 CT colonography

RCTYP_06 Other tests, Specify ________

97 - Don’t know

99 - REFUSED

if drectyp=06

DRECTYPO What other tests?

SECTION l: REASON FOR NO COLORECTAL CANCER SCREENING

if nevertested=1 or distanttest=1

REASNO. What is the MOST IMPORTANT reason why you have

[if NEVERTESTED=1: NEVER had any kind of test to look for problems in your colon or rectum]

[else if DISTANTTEST=1: NOT had any kind of test to look for problems in your colon or rectum RECENTLY]?

[INTERVIEWER: IF RESPONDENT GIVES MORE THAN ONE ANSWER OPTION, PROBE FOR THE MOST IMPORTANT REASON]

01 No reason/never thought about it

02 Didn't need it/didn't know I needed this type of test

03 Doctor didn't order it/didn't say I needed it

04 Haven't had any problems

05 Put it off/Didn't get around to it

06 Too expensive/no insurance/cost

07 Too painful, unpleasant, or embarrassing

08 Preparation requirements

09 Had another type of colorectal exam [Specify exam name: _________]

10 Don't have doctor

11 Other, Specify

97 - Don’t know

99 - REFUSED

if reasno=09

REASNOEX What is the name of the exam?

if reasno=11

REASNOTH Enter other response

SECTION M: COLORECTAL CANCER SCREENING INTENTIONS

[BASE: All respondents]

INTENT1. In the future, do you intend to get tested for colorectal cancer?

01 yes

02 no

97 don’t know

99 refused

if intent1 in (2, 97, 99)

INTENT2. Do you plan to talk to your doctor about colorectal cancer screening tests?

01 yes

02 no

97 don’t know

99 refused

SECTION n: PRIOR EXPERIENCE WITH COLORECTAL CANCER, PERSONAL, AND FAMILY HISTORY

[BASE: All respondents]

FRNDTST. Do you know anyone who has had a colorectal cancer screening test?

01 yes

02 no

97 don’t know

99 refused

[BASE: All respondents]

EVDIAG. Have you ever been diagnosed by a doctor or health care provider as having colorectal cancer or polyps in your colon?

[IF NECESSARY: “a polyp is a small growth that develops on the inside of the colon or rectum”]

01 yes

02 no

97 don’t know

99 refused

IF EVDIAG=1

DIAGNOS. Was the diagnosis:

[READ LIST]

01 Polyps

02 Colorectal cancer (colon cancer)

03 Or something else?

97 - Don’t know

99 - REFUSED

IF DIAGNOS=03

DIAGNOSO. What was the other diagnosis?

ENTER OTHER RESPONSE

[BASE: All respondents]

FAMDIAG. Have any of your brothers, sisters, or parents ever had colorectal cancer?

01 yes

02 no

97 don’t know

99 refused

SECTION o: HEALTH CARE

[BASE: All respondents]

Preq5. These next questions ask about your use of health care services. When answering these questions, please think about your own personal health and health care only.

[BASE: All respondents]

PERSDOC. Do you have one person you think of as your personal doctor or health care provider?

01 yes

02 no

97 don’t know

99 refused

if PERSDOC IN (2,97,99)

MULTDOC. Is there more than one, or is there no person who you think of as your personal doctor or healthcare provider?

01 MOre than one

02 no one

97 don’t know

99 refused

[BASE: All respondents]

COSTDOC. Was there a time in the past 12 months where you needed to see a doctor or health care provider but could not because of cost?

[IF NECESSARY “This also includes dental, eye or mental health care providers”]

01 yes

02 no

97 don’t know

99 refused

[BASE: All respondents]

TIMEDOC. About how long has it been since you last visited a doctor or health care provider?

[READ IF NECESSARY]

01 Within past year (anytime < 12 months ago)

02 Within past 2 years (1 year but <2 years)

03 Within past 5 years (2 years but <5 years ago)

04 5 or > years

05 Never

97 - Don’t know

99 - REFUSED

[BASE: All respondents]

COMORB. Do you have any medical conditions that require you to visit a doctor or health care provider regularly?

[If R asks “what is meant by regularly”, RESPOND with “visiting a doctor or health care provider at least 3 times a year for the same condition”]

01 yes

02 no

97 don’t know

99 refused

SECTION p: EXPOSURE TO CRCCP PROGRAM ACTIVITIES

///PROGRAMMER: THE FOLLOWING ARE THE CAMPAIGN NAMES TO ASSIGN TO EACH STATE:

Nebraska: “Stay in the Game” or “It’s time”

Alabama: “Fitway” or “Fight Back”

Washington: No media campaign

Tennessee: No media campaign

Oklahoma: No media campaign

Wisconsin: No media campaign ///

]
//ALL RESPONDENTS//

UNAIDAWR. In the past 12 months, have you read, seen, or heard anything to encourage people to get tested for colorectal cancer in your community?

01 yes

02 no

97 don’t know

99 refused

[base: if UNAIDAWR=1

ACT. Can you briefly describe where you read, saw or heard this?

enter response

[BASE: All respondents]

SNET1. In the past 12 months, did a member of your immediate family or a close friend talk to you about colorectal cancer screening?

01 yes

02 no

97 don’t know

99 refused

[BASE: ASK IF STATE=ALabama or nebraska]

AIDAWR. In the past 12 months, have you read, seen, or heard anything about the [//if AL insert “Fitway” or “Fight Back”// //if NE insert “Stay in the Game” or “It’s time”//] ] colorectal cancer screening campaign?

01 yes

02 no

97 don’t know

99 refused

[base: if aidawr=1
mul=9

AWRSRC. Where have you read, seen, or heard anything about [//if AL insert “Fitway” or “Fight Back”// //if NE insert “Stay in the Game” or “It’s time”//]?

[SELECT ALL THAT APPLY]

[DO NOT read response options]

[Select the response options that most closely correspond to the participant’s response]

AWSRC_01 On the television

AWSRC_02 On the radio

AWSRC_03 On a billboard

AWSRC_04 At a SPORTING EVENT (E.G., football game)

AWSRC_05 In the newspaper

AWSRC_06 In a magazine

AWSRC_07 On the internet

AWSRC_08 IN A COMMUNITY-BASED SETTING (E.G., CHURCH, SCHOOL, MALL)

AWSRC_09 WORKPLACES

AWSRC_10 Other, Specify ________________________

97 - Don’t know

99 – REFUSED

if AWRSRC=10

AWRSRCO Where else have you read, seen or heard anything about [//if AL insert “Fitway” or “Fight Back”// //if NE insert “Stay in the Game” or “It’s time”//]?

Enter response

[base: if aidawr=1

ADWHEN. When was the last time you read, saw, or heard anything about [//if AL insert “Fitway” or “Fight Back”// //if NE insert “Stay in the Game” or “It’s time”//]?

[READ IF NECESSARY]

01 Less than a month ago

02 More than a month but less than three months ago

03 More than three months but less than six months ago

04 More than six months but less than a year ago

05 More than a year ago

97 - Don’t know

99 - REFUSED

[BASE: All respondents]

RECE. In the past 12 months, have you received any education materials on colorectal cancer screening? For example, these could include brochures, post cards, posters, DVDs, internet- or cell phone text message-based materials or individual teaching.

01 yes

02 no

97 don’t know

99 refused

[base: if RECE =1

RECESRC. What education materials on colorectal cancer screening have you received?

[SELECT ALL THAT APPLY]

[DO NOT read response options]

[Select the response options that most closely correspond to the participant’s response]

RCESC_01 Print-based MATERIALS SUCH AS A BROCHURE, POSTER, POST CARD, LETTER, OR STICKER

RCESC_02 Audiovisual materials such as a DVD

RCESC_03 Internet-based materials

RCESC_04 Cell phone text messageS

RCESC_05 Individual teaching

RCESC_06 Other, Specify ________________________

97 don’t know

99 refused

if RECESRC=06

RECESRCO What are the other materials?

Enter response

if RECE =1

RECETIME. When was the last time you received these educational materials on colorectal cancer screening?

[READ IF NECESSARY]

01 Less than a month ago

02 More than a month but less than three months ago

03 More than three months but less than six months ago

04 More than six months but less than a year ago

05 More than a year ago

97 - Don’t know

99 - REFUSED

[BASE: All respondents]

RMND. In the past 12 months, have you received any reminders that it was time for you to be tested for colorectal cancer? A reminder could be in the form of a phone call, postcard or mailed letter, email or text message, or birthday card?

[If R asks “What kind of a reminder?” RESPOND WITH “A reminder that it’s time to be screened”]

[If R asks “A reminder from who?”, RESPOND with “It could have been sent by your doctor, health care provider office, nurse, community health center or insurance company”]

01 yes

02 no

97 don’t know

99 refused

IF RMND=1

RMNDSRC. How did you receive these reminders?

[SELECT ALL THAT APPLY]

[Select the response options that most closely correspond to the participant’s response]

01 During a doctor or health care provider visit

02 Phone call

03 Mailed LETTER

04 MAILED Postcard

05 Birthday card

06 Email message

07 TEXT MESSAGE

08 Other, Specify ________________________

97 dk

99 ref

if RMNDSRC=08

AWRSRCO How else did you receive these reminders?

Enter response

if RMND=1

RMNDTIME. When was the last time you received a reminder about colorectal cancer screening?

[READ IF NECESSARY]

01 Less than a month ago

02 More than a month but less than three months ago

03 More than three months but less than six months ago

04 More than six months but less than a year ago

05 More than a year ago

97 - Don’t knOW

99 - REFUSED

[BASE: All respondents]

These next set of questions are about services you may have received when planning or getting tested for colorectal cancer. Even if you have not been tested, you may have still used these services.

[BASE: All respondents]

INSUR. In the past 12 months, has anyone other than a family member or friend helped you obtain or enroll in health insurance?

01 yes

02 no

97 don’t know

99 refused

[BASE: All respondents]

TSTHELP. In the past 12 months, has someone within your health care system helped you to plan for colorectal cancer screening? For example, someone may have helped arrange transportation, explained how the test will be conducted, given you a home blood stool test kit, or made an appointment for you.

01 yes

02 no

97 don’t know

99 refused

[base: IF TSTHELP=1]

TSTWHAT What did this person help you with?

[ENTER RESPONSE]

[BASE: All respondents]

RECOST. In the past 12 months, were you offered colorectal cancer screening tests at a reduced cost?

01 yes

02 no

97 don’t know

99 refused

[BASE: All respondents]

CRCWORK. In the past 12 months, has your workplace encouraged you to get tested for colorectal cancer? For example this encouragement may have been through a worksite wellness program, providing paid time-off, a flyer included with your pay stub, educational materials, or information in the work newsletter.

01 yes

02 no

97 don’t know

99 refused

SECTION P: SOCIO-DEMOGRAPHICS

You’re almost finished! This last set of questions are about your background.

[BASE: All respondents]

SEX. [READ ONLY IF NECESSARY] What is your gender?

[Do not read response options]

1 Male

2 Female

[BASE: All respondents and if AGE2=02]

AGE What is your age?

[ENTER response]

[RANGE: 0 – 96]

96=96 or more

97 - Don’t know/Not sure

99 - No response/refused]

//ASK IF AGE=0-49//

AGE2 I’m sorry, I just want to confirm, you said you are //recall AGE//?

CORRECT AS IS //go to HISP//
NO, NOT CORRECT //go back to AGE//

[BASE: All respondents]

HISP. Are you Hispanic or Latino?

01 yes

02 no

97 don’t know

99 refused

[BASE: All respondents]
multi = 6

MRACE. Which one or more of the following would you say is your race?

Are you…

[ENTER ALL THAT APPLY. IF R SAYS “HISPANIC,” PROBE FOR ONE OF THE LISTED RACE CATEGORIES]

01 White

02 Black or African American

03 Asian

04 Native Hawaiian or other Pacific Islander, or

05 American Indian or Alaska Native

06 Other

97 - Don’t know

99 - refused

[BASE: MRACE=6]

MRACEO.

record other race response

[BASE: All respondents]

MARITAL. Are you…..

01 - Married,

02 - Divorced,

03 - Widowed,

04 - Separated,

05 - Never married, or

06 - A member of an unmarried couple?

97 - Don’t know

99 - refused

[BASE: All respondents]

EDUCA. What is the highest grade or year of school you completed?

[READ IF NECESSARY]

[Select the response option that most closely corresponds to the participant’s response]

01 Never attended school or only attended kindergarten

02 Grades 1 through 8 (elementary)

03 Grades 9 through 11 (some high school)

04 Grade 12 or GED (high school graduate)

05 College 1 year to 3 years (some college or Technical school)

06 College 4 year or more (college graduate)

07 Graduate school (masters, doctorate)

97 - Don’t know

99 - REFUSED

[BASE: All respondents]

EMPLOY. Are you currently……

[READ LIST]

01 Employed for wages,

02 Self employed,

03 Out of work for more than one year,

04 Out of work for less than one year,

05 A homemaker,

06 A student,

07 Retired, or

08 Unable to work?

97 - Don’t know

99 - refused

[BASE: All respondents]
[RANGE: 0 – 96]

CHILDREN. How many children less than 18 years of age live in your household? _________

IF THE RESPONDENT SAYS ‘NONE’, ENTER 0

[ENTER response]

97 don’t know

99 refused

[BASE: All respondents]

CARE. Are you responsible for caring for any children or older people?

01 yes

02 no

97 don’t know

99 refused

[BASE: All respondents]

INCOME. What was your estimated household income from all sources in 2010? Was it........

[IF RESPONDENT REFUSES AT ANY INCOME LEVEL, CODE ‘99’ REFUSED]

[If R asks for clarification on who should and should not be included in the income calculation state “Thinking about members of your family living in this household, what is your combined annual income, meaning the total pre-tax income from all sources earned in the past year”]

INCOME0 Less than $25,000 [IF “NO,” ASK 05; IF “YES,” ASK 03]

($20,000 to less than $25,000)

01 Yes

02 No

97 Don’t Know

99 Refused

[base: ask if income0= 01//

INCOME03 Less than $20,000 [IF “NO,” CODE 04; IF “YES,” ASK 02]

($15,000 to less than $20,000)

01 Yes

02 No

97 Don’t Know

99 Refused

/[base: ask if income03 = 01//

INCOME02 Less than $15,000 [IF “NO,” CODE 03; IF “YES,” ASK 01]

($10,000 to less than $15,000)

01 Yes

02 No

97 Don’t Know

99 Refused

[base: ask if income02= 01//

INCOME01 Less than $10,000 [IF “NO,” CODE 02]

01 Yes

02 No

97 Don’t Know

99 Refused

[base: ask if income0= 02//

INCOME05 Less than $35,000 [IF “NO,” ASK 06]

($25,000 to less than $35,000)

01 Yes

02 No

97 Don’t Know

99 Refused

[base: ask if income05 = 02//

INCOME06 Less than $50,000 [IF “NO,” ASK 07]

($35,000 to less than $50,000)

01 Yes

02 No

97 Don’t Know

99 Refused

[base: ask if income06 = 02//

INCOME07 Less than $75,000 [IF “NO,” CODE 08]

($50,000 to less than $75,000)

01 Yes

02 No

97 Don’t Know

99 Refused

[base: ask if income07 = 02//

INCOME08 $75,000 or more

01 Yes

02 No

97 Don’t Know

99 Refused

[base: ask if INCOME0-INCOME08 ne 97,99//

INCOMEA Your Annual Household Income is [enter range from code in INCOME0-08]

Is This Correct?

1 No, re-ask question [GO TO INCOME0]

2 Yes, correct as is. [CONTINUE]

[BASE: All respondents]

LIVED. Have you lived in your state for two years or more?

01 yes

02 no

97 don’t know

99 refused

[BASE: All respondents]

HINS. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?

01 yes

02 no

97 don’t know

99 refused

IF HINS=1
MULTI=8

HINSTYPE. What type of health care coverage do you have?

[READ LIST]

[SELECT ALL THAT APPLY]

HINTP_01 Insurance through a current or former employer or union (or this person or other family member)

HINTP_02 Insurance purchased directly from an insurance company

HINTP_03 Medicare

HINTP_04 Medicaid, medical assistance, or any kind of government-assistance plan for those with low-incomes or a disability

HINTP_05 Tricare or other military health care

HINTP_06 VA

HINTP_07 Indian health service

HINTP_08 Any other type of health insurance or health coverage plan, please specify_____________________

97 - Don’t know/Not sure

99 - No response/refused

//ASK IF HINTP_08=01//

HINTPO

ENTER RESPONSE

IF HINS=1

HINSWO. In the last 12 months, was there a time where you were without health insurance?

01 yes

02 no

97 don’t know

99 refused

[BASE: All respondents]

Those are all of the questions that we have today—thanks for your time and thoughtful responses. And thank you for helping us to learn about your thoughts on colorectal cancer screening.

We talked about several types of colorectal cancer screening during this interview. Any questions you may have about your need for any of the screening tests we discussed today should be discussed with your doctor. You can also find more information about cancer at the website for the Centers for Disease Control and Prevention at www.cdc.gov/cancer.

Do you have any questions for me regarding this survey? [ANSWER ANY QUESTIONS]

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	Colorectal Cancer Population Survey
Author	Kawonda.l.Holland
File Modified	0000-00-00
File Created	2021-01-28

Colorectal Cancer Population Survey

Impact Evaluation of CDC's Colorectal Cancer Control Program

ATT 4A Colorectal Cancer Population Survey_7.18.2013

Colorectal Cancer Population Survey

OMB: 0920-0992

Form Approved

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