Sceener

Insurance Coverage, Employment Status, and Copayments/Deductibles Faced by Young Women Diagnosed with Breast Cancer

Attachment 4-scr - Intro_Screening for Web-bsed Survey English

Breast Cancer in Young Women screener and survey - survivors from advocacy groups

OMB: 0920-1123

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Attachment 4-scr: Intro/screening for 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 2)
Pages 6-7: Screening Questions (Sample 2)
Page 8: Ineligibility Page (Sample 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 left blank, the participant will be directed to this information page for Sample 2:

5

Sample 2 then proceeds with 4 eligibility questions.

6

7

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.

8


File Typeapplication/pdf
AuthorEdwards, Patrick
File Modified2016-02-05
File Created2016-02-05

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