Survey- Word Version

Attachment B: Survey Items

[This page for all individuals]

OMB No: 0925-0645
Expiration Date: 11/30/17

Public reporting burden for this collection of information is estimated to average 30 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 (0925-0645). Do not return the completed form to this address.

Consent Form

Life Events Study

Alcohol and Breast Cancer Study

National Cancer Institute

Overview:

Today, you will be asked to participate in two studies; each study is relatively short (adding up to a total of about 30 minutes for both studies), so we have combined them for convenience.

Why is this research being done?

In the first study, Life Events, we are interested in learning about various aspects of life and how they make people feel. In the second study, Alcohol and Breast Cancer, we are interested in learning about how people respond to information about alcohol and breast cancer.

Who is being asked to take part in these research studies?

We are asking women aged 18 and older to take part in these studies. Because the second study involves examining reactions to a message about the link between alcohol and breast cancer, women are only eligible for this study if they consume five or more alcoholic beverages per week.

What procedures will be performed for research purposes?

If you agree to be in these studies, you will be asked to do the following:

Life Events Study

1. Write a paragraph or two about something that has happened to you in your life or another aspect of your life.

2. Answer several questions about that event.

3. Write a paragraph or two about a value that is important to you.

Alcohol and Breast Cancer Study

1. Read information about the link between alcohol and breast cancer.

2. Answer questions about the information you read and your beliefs about alcohol and breast cancer.

The total time required to complete both of these studies should be approximately 30 minutes.

What are the benefits and risks to participation?

Participants will help contribute to the body of knowledge in social and health psychology. These studies do not include any medical procedures, and present minimal risk. Risks include any discomfort you may feel while writing about life events or reading about the link between alcohol and breast cancer.

Is participation voluntary?

Your participation in these studies is entirely voluntary and you may refuse to complete either study at any point, even after you give consent to participate, or refuse to answer any questions with which you are uncomfortable.

Who will know which specific individuals have chosen to participate in these research studies?

Your name and other identifying information will not be connected to your results or to your responses on the questionnaires. Information that would make it possible to identify you or any other participant will never be included in any report or publication of results. The coded data will be accessible only to those working on the project. Data collected for these projects will be stored, but will not be connected with your name or any other identifying information, and so no one working with the data will know which specific individuals have chosen to participate in these research studies.

Contacts and Questions:

If you have questions about the Life Events Study, you may contact Rebecca Ferrer at rebecca.ferrer@ nih.gov. If you have questions about the Alcohol and Breast Cancer Study, you may contact William Klein at [email protected].

Statement of Consent:

I have read the above information, and I understand that I am encouraged to contact the researchers listed if I have any questions about either study. I consent to participate in these studies.

Please click to continue to the studies. Clicking to continue indicates your consent to participate in these studies.

Thanks for your participation!

[This page for Conditions 1 and 6]

Please briefly describe 3-5 things that currently make you very happy.

Please describe in more detail the one recent situation that has made you most happy. Write your description in such a way that someone reading it might even become happy just from learning about the situation. You should write a few paragraphs, or for about five minutes.

[This page for Conditions 2 and 7]

Please briefly describe 3-5 things that currently make you very fearful.

Please describe in more detail the one recent situation that has made you most fearful. Write your description in such a way that someone reading it might even become fearful just from learning about the situation. You should write a few paragraphs, or for about five minutes.

[This page for Conditions 3 and 8]

Please briefly describe 3-5 things that currently make you very angry.

Please describe in more detail the one recent situation that has made you most angry. Write your description in such a way that someone reading it might even become angry just from learning about the situation. You should write a few paragraphs, or for about five minutes.

[This page for Conditions 4 and 9]

Please briefly describe 3-5 things that currently make you very surprised.

Please describe in more detail the one recent situation that has made you most surprised. Write your description in such a way that someone reading it might even become surprised just from learning about the situation. You should write a few paragraphs, or for about five minutes.

[This page for Conditions 5 and 10]

Please list a few items in a room in your house.

Please describe in more detail the room where these items can be found. You should write a few paragraphs, or for about five minutes.

[This page for all participants]

On a scale of 1 to 7

How much do you currently feel happy?

How much do you currently feel afraid?

How much do you currently feel angry?

How much do you currently feel surprised?

1 2 3 4 5 6 7

Not at all Extremely

[This page for Conditions 1 – 5]

In this study we are interested in investigating values. By values we mean the moral principles and standards by which people try to live their lives. For example, honesty might be a core value for some people. That is, they may try to be honest in all they do when dealing with other people.

Please look at the list of values below, and check the one that is most important to you.

Artistic skills

Athletics

Business/earning money

Compassion

Conscientiousness

Creativity

Friendliness

Generosity

Hedonism (the pursuit of pleasure/happiness)

Honesty

Independence

Intelligence

Kindness

Musical ability/appreciation

Politics

Relations with friends or family

Spirituality/Religiousness

Sense of Humor

Spontaneity/Living life in the moment

Trustworthiness

Other: (write in)________________________

Please type a short statement about why this value is important to you. Take a few minutes to think about this value and how this value has influenced your past behaviors or attitudes. Please write about how you use this value in your everyday life – at work, at home, with friends, or in dealing with strangers. If you can, try to recall and write about specific occasions on which this value determined what you did.

[This page for Conditions 6 – 10]

In this study we are interested in investigating values. By values we mean the moral principles and standards by which people try to live their lives. For example, honesty might be a core value for some people. That is, they may try to be honest in all they do when dealing with other people.

Please look at the list of values below, and check the one that is least important to you.

Artistic skills

Athletics

Business/earning money

Compassion

Conscientiousness

Creativity

Friendliness

Generosity

Hedonism (the pursuit of pleasure/happiness)

Honesty

Independence

Intelligence

Kindness

Musical ability/appreciation

Politics

Relations with friends or family

Spirituality/Religiousness

Sense of Humor

Spontaneity/Living life in the moment

Trustworthiness

Other: (write in)________________________

Please type a short statement about why this value could be important to another person. Take a few minutes to think about how this value may influence this person’s behaviors or attitudes. Please write about how this person may use this value in everyday life – at work, at home, with friends, or in dealing with strangers. Only think about why this value might be important to another person, and not why it is unimportant to you.

[This page for all participants]

Alcohol & Breast Cancer

Drinking a single alcoholic drink a day increases a woman's chance of developing breast cancer, according to a 2008 quantitative review and synthesis of many studies examining the association of alcohol and breast cancer. Further, a recent 2011 study in the Journal of the American Medical Association found that consumption of 3-6 alcoholic drinks per week carried a 15%increased risk of breast cancer. Dr. Wendy Chen of Brigham and Women’s Hospital in Boston, and lead author of this study, stated “There aren’t many modifiable risk factors for breast cancer, so it’s important to think about this.”

How much alcohol?

"The recommendation would not be to stop drinking altogether, but to keep it below the range of three to six glasses a week," Chen said. Alcohol may increase the risk of breast cancer by raising the levels of estrogen in the body. Estrogen has a well-established link with breast cancer, with research suggesting estrogen can play a role in both triggering its development and encouraging the growth of tumors.

Drinking too much could be dangerous

Considering the potential harmful effects of drinking, including breast cancer, it is advised that those who do drink more than 7 drinks per week should cut down their consumption. Additionally, based on recent evidence, women who drink even 3-6 drinks per week might consider cutting down their consumption. According to the U.S. Department of Health and Human Services, women should not exceed 1 serving per day (12 oz. of beer, 5 oz. of wine, or 1.5 oz. of hard liquor) and should drink no more than 7 servings per week.

[This page for all participants]

On a scale of 1 to 7

How much do you currently feel happy?

How much do you currently feel afraid?

How much do you currently feel angry?

How much do you currently feel surprised?

1 2 3 4 5 6 7

Not at all Extremely

• I intend to decrease my alcohol consumption in the next 2 weeks.

1 2 3 4 5 6 7

Definitely will not do Definitely will do

• If you have any interest in altering your alcohol consumption in the next 7 days, how will you go about it? Please list below any steps that you think you will take to reduce your alcohol consumption.

• How worried are you about developing breast cancer in the future?

1 2 3 4 5 6 7

Not at all worried Extremely worried

• Overall, how do you think your chance of developing breast cancer compares to the average woman your age?

1 2 3 4 5 6 7

Much lower About the same Much higher

• I feel very vulnerable to breast cancer.

1 2 3 4 5 6 7

Strongly disagree Strongly agree

• The evidence linking alcohol and breast cancer is convincing

1 2 3 4 5 6 7

Strongly disagree Strongly agree

• To learn more about the link between alcohol and cancer (including breast cancer), go to: http://www.cancer.gov/cancertopics/factsheet/Risk/alcohol