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Form Approved
OMB No: 0920-xxxx
Exp. Date: xxJxxJxx
Welcome to CDC's Women's Health Study Survey!
The survey is being conducted to help the Centers for Disease Control and Prevention (CDC) better
understand the health of women in your metropolitan area, identify effective strategies to address
women's health issues, and improve the health of women around the nation. Your participation in
this survey will help CDC better communicate with women about their health. Your participation is
very important and is completely voluntary. You may refuse to answer any of the survey items you
wish. We anticipate it should take no more than 20 minutes to complete the survey. If you need to
stop the survey and come back to it later, you may exit the survey and log in again later to complete
il. All of your responses will be saved.
Please call «PHONE», visit «WEBLINK TO INFORMATION SHEET», or email «EMAIL» if
you have any questions or want more information. If you have technical problems or questions
about the survey items, please contact [NAME] at Battelle at [PHONE] or [email]. If you agree to
participate and are ready to begin the Women's Health Study Survey, please click on the Agree to
Participate and begin survey link below to proceed. Thanks again for your time and input! Please
complete and submit your survey responses on or before [DATE].

Public Reporting burden of this colleclion of informalion varies from 3 to 20 minutes with an average of average 20 minutes per response,
including the time for reviewing instructions.

searching existing dala sources, gathering and maintaining the dala needed. and completing

and reviewing the collection of information. An agency may not conduci or sponsor, and a person is not required to respond to a collection
of informalion

unless

it displays

CI

currently valid OMB conlrol number. Send comments regarding this burden eslimale or any other aspect

of this collection of inforrnation. including suggestions for reducing this burden to COC/ATSDR Reports Clearance Officer. 1600 Clifton
Raad NE, MS 0-74, Atlanta, Georgia 30333; AnN: PRA (0920-xxxx).

(.) Agree to participate and begin survey

C)

Decline to participate

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Near which city do you live?

c)

Cincinnati

()

Las Vegas

CJ

Milwaukee

o

San Antonio

()

Other

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How long have you lived at this area?

o

Less than 6 months

()

6-12 months

()

More Ihan a year

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How old are you?

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What is your gender?

o

Female

C)

Male

()

Transgender

Cl

Other

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To begin, we'd like to ask you some questions about health in general.
In general, how would you describe your own health?
,',
\,)

Excellent

C; Very Good

Cl

o
o
;'_)

Good
Fair
Poor
Don't Know

Have you heard of any of the following? (SELECT ALL THAT APPLY)
Yes
Colposcopy

(close-up examination of cervix)

Human papillomavirus (HPV) infection
HPV test
HPV vaccine

o
o
o
O
O

Hysterectomy
Mammogram

o

Pap test (Pap smear)

o

Pelvic examination
Transvaginal ultrasound
vagina)

(probe inserted into

o

Anal Cancer

()

Bladder Cancer

o

Cervical cancer

o

Colareelal cancer

o

Colareelal polyps

O

Endometrial cancer

o

Fallopian tube cancer

O

Gynecologic cancer

o

Ovarian cancer

()

Ovarian cysts

O

Uterine cancer

o

Uterine Fibroids

O

Vaginal cancer

o

Vulvar cancer

Cl

To the best of your knowledge, which of the following are types of gynecologic cancer? (SELECT
ALL THAT APPLY)
] Anal Cancer

:J

Bladder cancer

__j

Breast cancer

····i

Cervical cancer

.J

Colareetal

:J
:J

Endometrial cancer

cancer

Fallopian tube cancer

] Ovarian cancer

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Uterine cancer

']

Vaginal cancer

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. ! Vulvar cancer
., None of these
.... J

How concerned are you about getting the following

diseases in the future?

Nol at ali Concerned

Not Very Concerned

Somewhat Concerned

Breast cancer

o

,'"

C)

Cervical cancer

n
\..J

o
o

o

o

Colorectal cancer

o

Cl

"-.J

,_'

Diabetes

o

o

-,,)

C_)

C)

'~,J

,_)

o

;.,

Endometrial cancer

\.)

Fallopian tube cancer

o

Heart disease

C

Ovarian

r>:

cancer

Very Concerned

,'-,

O
O

',~)

O
C)

C)

.....)

o

cancer

o

r,
\....}

Cl

C¡

Vaginal cancer

C

O

O

o

Vulvar cancer

o

o

o

C!

Uterine

To the best of your knowledge, the reason to have a Pap test or Pap smear is to check for which of
the following? (SELECT ALL THAT APPLY)
Anal cancer

=:J
::J

Cervical cancer

",-,",]

Coloreclal

~]

Endometrial

Bladder cancer

cancer
cancer

:_j Fallopian lube cancer

", J

Human papillomavirus

. .]

Pregnancy

~

Ovarian cancer

:J

Ovarian cysts

... J

Sexually transmitted diseases/infections

.:J

Uterine cancer

~]

Uterine fibroids

(HPV)

(other than HPV)

.. _] Vaginal cancer
'.'~] Vulvar cancer

::J

None of these

Which,

if any, of the following

may be a warning

sign or symptom of gynecologic

cancer?

Yes

No

Not Sure

\_/

i":

O

C)

Change in bathroom habits,
such as constipation or diarrhea

C)

O

Ci

Feeling full after eating a small
amount of food

("',

O

n

o

A period that lasts for an
unusually long time or is
heavier than usual for you

'-,

U

A rash or sore on your genitals,
or the skin on your genitals
becoming redder or whiter in
color

(",

'J

O

Unexplained pelvic or
abdominal pain

()

\"

Cl

Unexplained

,~

O

()

back pain

,C)

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Yes

No

,""'l
\~/

O

o

o

1-',

urgently Ihan usual

()

o

r'\
' . .r

Vaginal bleeding (not related to
your period) afler sex

r-:

\...J

O

o

C)

O

r>:
\_)

üiïe'x'pläïneÏ:ftiiöaÚng
Unexplained vaginal bleeding
between periods or after you
have gone through menopause

Urinating more often or more

Vaginal ilching thai does not
gel better with over-the counter
treatments/creams

Nol Sure

'-l

If you began experiencing any of the following and it was not normal for you, when would you contact a doctor
or other health professional?

I would probably
Within a few days

Within

1-2 Weeks

After several
weeks

After several
months

not contact a
doctor

A period that lasts for an
unusually long time or is
heavier than usual for you

O

o

O

(-\

,,,'

o

Change in bathroom habits,
such as constipation or diarrhea

O

o

O

o

o

Feeling full after eating a small
amount of food

o

r·'
,--,

C)

r-»:

O

A rash or sore on your genitals,
or the skin on your genitals
becoming redder or whiter in
color

o

o

O

Unexplained pelvic or
abdominal pain

o

C)

O

Unexplained back pain

C)

o

O

'.j

n

O

Unexplained bloating

CJ

i·'J·"

o

o

o

\_,)

o

O

()

O

Urinating more often or more
urgenlly than usual

O

('

O

o

o

O

o
.. "
u

O

Vaginal bleeding (not related to
your period) after sex

;

(

Vaginailiching thai does noi
get better with over-the-counter
treatments/creams

Cl

o

o

C)

O

Unexplained vaginal bleeding
between periods or after you
have gone through menopause

,j

\_1

, .. ,
\_/

, ..
\j

,

O

'",

l ..

,.')

..

Have you ever experienced any of the following symptoms for two or more weeks: bloating, pelvic or abdominal pain,
difficulty eating or feeling full quickly, or having to go to the bathroom more often and more urgently?

C)

Yes

....:,,)', No
r-,
;'j

Not Sure

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When you experienced these symptoms, did you speak with your healthcare provider?

o

Yes, I made an appointment to find out what was causing the symptoms

C)

Yes, I had an appointment already scheduled

Cl Yes, I had a telephone consultation

o

No

C) Not sure

Approximately how long were you experiencing the symptoms before you spoke with your heallhcare provider?

C)

Within a 1 to 6 days

(J Within 1-2 weeks

C)

Within 1 month

o

Within 2 to 5 months

r'>;

Cl

Within 6 months to a year
After a year or more

For the next series of questions, please indicate how strongly you agree or disagree with the following statements.

I am familiar with my body and know what is
normal for me.

Agree

Neither Agree
nor Disagree

Disagree

Strongly
Disagree

o

o

o

o

If I noticed any changes in my body thaI lasted for
two weeks or longer and were not normal for me, I
would talk to a healthcare provider and ask about
possible causes including gynecologic cancers.

o

'. ./

C)

O

C)

The symptoms of gynecologic cancer may be
caused by something other than cancer, but the
only way to know is to see a doctor.

C)

()

O

O

o

I would recommend that my friend see the doctor if
she were experiencing any of the following
symptoms for two weeks or longer: bloating, pelvic
or abdominal pain, difficulty eating or feeling full
quickly, vaginal bleeding between between periods
or after menopause, and urinary urgency or
frequency.

()

o

O

O

C)

I would see my healthcare provider if I experienced
any of the following symptoms for two or more
weeks: bloating, pelvic or abdominal pain, difficulty
eating or feeling full quickly, or having to go to the
bathroom more often and more urgently.

o

C)

O

o

r--;
\_;

In the next 6 months I will look for more information
on the signs and symptoms of gynecologic
cancers.

C)

o

O

C)

Cl

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On average, how many hours a day do you spend:

10

12

14

16

18

20

22

24

Watching television,
weekdays

Using the internet for
personal reasons

In the past 30 days have you seen, heard, or read any TV, radio,
or messages about any of the following? (Select all that apply)

:J
.~

newspaper, or online advertising

Encouraging women to see a doctor if they have symptoms that are not normal for them
Encouraging women to know their body and what is normal for them

"]

Urging women to lisien to Iheir bodies

... J
'."J

Encouraging women to learn the signs and symptoms of gynecologic

cancers

None of these

Thinking of the messages that you saw or heard in Ihe past 30 days Ihat encouraged women to speak to a doclor if they
are experiencing

symptoms

not normal for their bodies,

:. . .]

Newspapers or magazines

',']

Billboards

~]

TV

']

Web sites

,J

Online ads

Please

select all that apply.

or posters

or radio

::J

Facebook

:J

Twitter

.. .".1 Materials

at work (e.q. posters, pamphlets,

=:J

Materials at a doctor's office (e.q.

:J

Somewhere else nollisled

~.']

where did you see or hear them?

posters,

etc.)
pamphlets,

etc.)

(please specify)

Don'l remember

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Have you seen any advertisements about gynecologic cancer in the past 30 days?

o
C)
C)

Yes

No
Not Sure

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In the past 30 days, how often have you seen or heard advertising

o

Page 1 of 1

about gynecologic

cancer?

About every day

()

Several times a week

C')

About once a week

o

Less than once a week

\..J

Not

()

Don't know

at all

Have you ever heard of the Inside Knowledge Campaign?

(J

Yes

C)

No

C)

Nol Sure

Have you ever seen this logo?

."'.".,

Yes

C)

No

'_}
"

Not Sure

/

Who sponsored this ad?

C)

Please enter the ad name of the sponsor in the box below

()

I don', remember

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Now, we would like you to view a television advertisement that has been shown in the U.S. \/vhen you are ready, please
click on the link below to view the advertisement. After you view the ad, there will be a few questions that ask about your
opinions of the ad.

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As you viewed this ad, were the sound and video clear enough for you to rate the ad?

o

Yes

()

No

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Have you seen this ad before today?

o

Yes

Cl

No

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Did you speak with any of the following people about this ad? (Select all that apply)
_j Yes, a friend

=:J

Yes, a family member

.. 1

Yes, a healthcare provider

.....1 Yes, someone else

:l

Please

No, I didn't speak to anyone

tell us how strongly

tollowlnç statements.

you agree or disagree with the

Strongly Agree

Agree

Neither Agree nor
Disagree

Disagree

Strongly Disagree

This ad is convincing.

O

o

O

o

o

This ad is informative.

Cl

C)

(J

..
\_;

O

This ad laid me something new.

o

r-;
l,._)

(

o

o

This ad is meaningful to me.

C)

o

O

»<:
\.)

O

This ad was irritaling.

Ci

('

o

o

This ad made me afraid.

o

v.:
r-;

(",

-,,-'

C)

Likely

Very Likely

r,

\.)

.

O

{

,

After watching this ad, how likely are you lo do the following:
Very Unlikely

Unlikely

Undecided

Schedule an appointment to
talk with my heallhcare
provider.

o

,",

Track any symptoms that are
noi normal for you.

C)

C)

O

C)

Learn about the siqns and
symptoms of gynecologic
cancer.

O

r--;

o

C)

Call a healthcare provider if you
experience, or have been
experiencing, symptoms thai
are not normal for you.

o

C.)

()

U

\,j

C)

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Lastly, we'd like to ask you some questions for classification purposes.
Do you consider yourself lo be Hispanic, Latina, or of Spanish origin?

()

Yes

Cl

No

VV'hat is your race? (SELECT ALL THAT APPl v)

:=J

American

:1

Asian

...]

Black or African American

Indian or Alaska Native

"o"_]

Native Hawaiian or other Pacific Islander

~J

While

What is the highest level of school you have completedor the highest degree you have received?

~~) No schooling completed, or less than 1 year
()

Nursery, kindergarten, and elementary (grades 1·8)

,)

High school (grades 9-12, no degree)

()

High school graduate (or equivalent)

C)

Some college (1-4 years, no degree)

()

Associate's degree (including occupational or academic degrees)

C)

Bachelor's degree (BA, SS, AB, etc)

C)

Master's degree (MA, MS, MENG,

()

Professional school degree (MD, DOC, JO, etc)

(J

Doctorale degree (PhD, EdO, etc)

MSW, ele)

The next question is about the total income of YOURHOUSEHOLD for the PAST 12 MONTHS. Please include your
income PLUS the income of all members living in your household (including cohabiting partners and armed forces
members living at home), Please count income BEFORE TAXES and from all sources (such as wages, salaries, tips, net
income from a business, interest, dividends, child support, alimony, and Social Security, public assistance, pensions, or
retirement benefits).
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?

o

SO lo S9,999

('ì

S10,000 lo S14,999

o

S15,000 lo S19,999

O

S20,000 lo 534,999

o

535,000 lo S49,999

o

S50,000 lo $74,999

C)

S75,000 lo S99,999

o

5100,000

o

5200,000 or

lo 5199,999

more

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Are you currently ... ?

o

Married

C)

Living

Cl

Divorced

o

Widowed

Cl

Separated

with a partner

C) Single (that is, never married and noi currently living with a partner)

V\lhich statement

best describes

your current employment

status?

C) Working full time (35 or more hours per week)

;_J

Working

()

Unemployed

part time (less than 35 hours per week)

() Retired
()

Student

O

Homemaker

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Has anyone in your family (i.e., any blood relative) ever had any of the following (PLEASE SELECT ALL THAT APPLY):

:J

Breast cancer

:J

Cervical cancer

~

Gynecologic cancer

:J

Ovarian cancer

Endometrial

cancer

. ... ) Uterine cancer
.~]

Vaginal cancer

:. ..J Vulvar cancer
.... j Fallopian

'.'~J
::J
::J

lube cancer

Other cancer
None of the above
Don't know

Doctors often cannot explain why one person develops cancer and another does not. Research shows that certain risk
factors increase the chance that a person will develop cancer Has a doctor or other health care provider/professional
ever laid you are at increased risk for any type of cancer?
r-;

v

/.,

o

Yes
No
Not sure

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Have you been laid Ihal you were at increased risk for any of Ihe following cancers (PLEASE SELECT ALL THAT
APPLY.)

:::J
_]

......

Breast cancer
Cervical cancer

::::J

Endometrial

,j

Gynecologic cancer

cancer

····ì
.... .1

Ovarian cancer

"..., J

Uterine cancer

:J

Vaginal cancer

]

Vulvar cancer
Fallopian lube cancer

Has a doctor or other heallhcare provider/professional ever laid you that you have any of Ihe following? (PLEASE
SELECT ALL THAT APPLY)

~J

Breast cancer

:::J

Cervical cancer

. .1

Endometrial

.J

Gynecologic cancer

~J

Ovarian cancer

:J

Uterine cancer

cancer

] Vaginal cancer

_.J

Vulvar cancer

.=:J

Fallopian lube cancer

....]

Abnormal Pap tesi (Pap smear)

......]

Endometriosis

:J

Human papillomavirus (HPV) infection

~

Other Iype of cancer

·.·.· 1

I have never been tord I have any of these

Have you gone through

Cì

Yes

o

No

C)

I'm going through

~.)

Nol sure

menopause

(end of menstruation)?

it now

Do you have any kind of health care coverage, including health insurance or government plans such as Medicare or
Medicaid?

o

Yes

f··' No
. . ..J
;.)

Not

sure

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Thank you for your time today.
We appreciate you sharing your opinions!
Please

click submit

to finish

your survey.

To learn more about Gynecologic cancer please visit the website below:
http://www.cdc.gov/cancer/knowledge/

C)

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