Patient Cover Letter - English

Attachment 5a

Patient Cover Letter, English

-CR Logo-

I was a freelance hairstylist when I found out I had cervical cancer. I never thought I would have cancer, but in 2009, I was diagnosed through the New York State Cancer Services Program. Because of the high cost of insurance for the self-employed, I didn’t have health insurance at the time. I recall feeling what I can only describe as an out-of-body experience that I will never forget. Within a few weeks of diagnosis, I began treatment that included both radiation and chemotherapy. Follow-up tests show I’m still cancer-free.

-Geraldine P., Cervical Cancer Survivor

Age at diagnosis: 62

Date

Participant Name

Address

City, State ZIP

Dear Ms. Participant Last Name,

We would like to invite you to take part in a research study called the Case Investigation of Cervical Cancer (CICC) Study that is being conducted by the ____ Cancer Registry in conjunction with ___ University and the Centers for Disease Control and Prevention (CDC). The purpose of this study is to better understand the screening and follow-up experiences of women prior to being diagnosed with cervical cancer and is sponsored by CDC.

Your name (as well as the names of approximately 600 others eligible for this study) was obtained from the ____ Cancer Registry, which was created by the state Legislature to help find the causes and cures of cancer. Every new diagnosis of cancer in state is required by law to be reported to the ____ Cancer Registry. Information about individuals diagnosed with cancer can only be released for research purposes to qualified researchers who agree to maintain the security of the information they collect, and upon approval from the Institutional Review Board for the ____ Cancer Registry.

Taking part in this study is entirely up to you. If you would like to take part in our study, please review the following documents:

1. Research Participant Information Sheet – This sheet provides more information about the study, its risks and benefits, and the protections we have set up to keep your information safe. Please keep this for your records.

2. CICC Survey – This survey provides information about your care experiences. Please complete the survey and return it in the Pre-Paid Envelope.

3. HIPAA Medical Record Release Authorization Form – This form would allow us to access the medical records related to your condition. We are asking to review your medical records because we would like to obtain detailed clinical information from your healthcare providers about your screening and follow-up visits, like the type of Pap or HPV test, the clinical results, and the type of treatment if any that was done prior to your diagnosis. You are not required to allow us to access your records, but this information can be very important to better understand ways to prevent cervical cancer.

If you will give us access to your medical records, please fill in the HIPAA Medical Record Release Authorization form and return it in the Pre-Paid Envelope (please return all three pages). Two copies of the form are provided. Please keep the second copy for your records.

4. Healthcare Source Form – This form will identify the medical providers that we should contact for your medical records. The____ Cancer Registry does not have a list of your healthcare providers. Providing a list of the healthcare providers that you saw for gynecologic and well woman preventive care prior to your diagnosis will allow the most complete picture of your care experiences and can be very important to better understand ways to prevent cervical cancer. If you will give us access to your medical records, please fill in the Healthcare Source Form and return it in the Pre-Paid Envelope.

In appreciation of your time, we will send you a gift card in the amount of $25 when we receive your completed materials.

Within the next few days, a member of the study staff may be calling you to answer any questions that you may have about the study. The telephone number we have for you is (PT Phone #). If this number is incorrect or if there is a different number where you may be reached, please feel free to contact ___, Study Manager, at (800) ___-____ (toll-free) or (___) ___-____.

I hope that you will consider joining other individuals who have chosen to participate in this important study. Thank you very much.

Sincerely,

Signature

Director name, PhD

Director, state Cancer Registry