Form 0920-0572 Screening Instrument for Young Women

Form Approved

OMB No. 0920-0572

Exp. Date 03/31/2018

Attachment B1:

Screening Instrument for

Young Women

Public reporting burden of this collection of information is estimated to average 3 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0572).

1. Gender: (1a)

• Male [terminate]

• Female

2. In which of the following categories does your age fall: (2a.)

• under 18 years of age [terminate]

• 18-23 years of age

• 24-29 years of age

• 30-37 years of age

• 38-45 years of age

• Older than 45 [terminate]

3. Which of the following websites or social media channels do you access once a month or more? Check all that apply.

• Facebook

• Twitter

• Instagram

• Pinterest

• Reddit

• YouTube

• Tumblr

• Snapchat

• Other (please specify)

• None [terminate]

4. Have you ever been diagnosed with breast or ovarian cancer? (44a.)

• Yes [terminate]

• No

5. Think about both your mother and father’s sides of your family. Include your parents, children, brothers, sisters, aunts, uncles, nieces, nephews, and grandparents. Have any of these family members been diagnosed with breast or ovarian cancer that you know of?

• Yes

• No

6. What is the highest level of education you have completed? (4a.)

• Less than high school graduate/some high school

• High school graduate or completed GED

• Some college or technical school

• Received four-year college degree

• Some post graduate studies

7. Please select any of the following you use to describe yourself. (You may select more than one)

• White/Caucasian

• Black or African-American

• Asian

• American Indian or Alaska Native

• Native Hawaiian or Other Pacific Islander

8. Are you Hispanic or Latina?

• Yes

• No

9. Are you of Ashkenazi Jewish descent?

• Yes

• No

10. In what zip code do you currently live? ENTER FIVE DIGIT ZIP CODE. (9a.)