Breast Cancer in Young Women - online survey

Attachment 4: Web-based Survey Instrument – English

Page 2: Landing Page (Sample 1 & 2)
Page 3: Language Selection (Sample 1 & 2)
Page 4: Survey Code (Sample 1 & 2)
Page 5: Information Page (Sample 1)
Page 6: Information Page (Sample 2)
Pages 7-8: Screening Questions (Sample 2)
Page 9: Ineligibility Page (Sample 2)
Pages 10-76: Survey Questionnaire (Sample 1 & 2)

1

2

3

If participant enters a code here, she will automatically be placed in Sample 1, and is already eligible to take the survey.
If left blank, the participant will be included with Sample 2 and her eligibility will be confirmed through the screener.

4

If the survey code is entered on previous page, the participant will be directed to this information page for Sample 1:

5

If the survey code is left blank, the participant will be directed to this information page for Sample 2:

6

Sample 2 then proceeds with 4 eligibility questions.

7

8

If a participant in Sample 2 responds “no” to any of S1-S3, or “yes” to S4, she will be ineligible to continue taking the
survey.

9

Sample 1 participants and eligible Sample 2 participants can proceed with the survey questionnaire.

10

11

12

13

14

15

16

If an answer to B1 is “My illness has had no impact on my household finances” then survey will skip B2 and proceed to
B3. (Please see mail-in survey instrument to clearly visualize the skip patterns).

17

18

19

20

21

22

23

24

25

26

27

If the answer to C1 is “no”, then survey will skip C2-C8 and will proceed with C9.

28

29

30

31

32

33

34

If answer to C9 is “Not now, but I plan to seek future employment” or “Not now, nor in the foreseeable future”, then
survey will skip C10, and proceed with C11. If answer to C9 is “Yes”, survey will proceed with C10.

35

After answering to C10, survey will proceed with C12.

36

37

38

39

40

41

If answer to D2 was “Yes”, then survey will skip D3 and proceed with D4.

42

43

44

45

46

If answer to D7 is “No”, then survey will skip D8-D10 and proceed with Section E.

47

If answer to D8 is “Yes”, then survey will skip D9 and proceed with D10.

48

49

50

51

52

53

54

55

56

57

58

59

60

61

Scroll down

62

63

64

65

66

67

68

69

70

71

72

73

74

If answer to H12 is “No”, then survey is complete. If answer to H12 is “Yes”, then survey will proceed with H13 before
completion.

75

76