WPHSS questionnaire

OMB #0920-xxxx

Exp. Date xx-xx-20xx

Women’s Preventive Health Services Survey (WPHSS) Questionnaire –

English Version

Public reporting burden of this collection of information is estimated to average 25 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-16AWP).

SCREENER QUESTIONS

SCREENER1. First, we need to confirm you are eligible for the study. Do you now have health insurance?

• YES [CONTINUE]

• NO [GO TO INELIGIBLE]

SCREENER2. Have you received a publically funded Pap test between [insert dates not less than 1 year but not more than 4 years from study implementation] or received a publicly funded Pap/HPV co-test between [insert dates not less than 3 years but not more than 5 years from study implementation]?

• YES [CONTINUE]

• NO [GO TO INELIGIBLE]

SCREENER3. Have you received a publically funded mammogram between [insert dates not less than 1 year but not more than 3 years from study implementation]?

• YES [CONTINUE]

• NO [GO TO INELIGIBLE]

SCREENER4. Are you a US citizen or do you have a green card?

• YES [CONTINUE]

• NO [GO TO INELIGIBLE]

SCREENER5. Are you a [Insert state] resident?

• YES [CONTINUE]

• NO [GO TO INELIGIBLE]

SCREENER6. Are you between the ages 30 and 62?

• YES [CONTINUE]

• NO [GO TO INELIGIBLE]

ELIGIBLE. Okay, great! It sounds like you are eligible for the survey. We would like to continue now unless you have any questions.

• CONTINUE [GO TO CONSENT]

INELIGBLE. Unfortunately, you are not eligible for the study at this time. Thank you for your time and your interest.

CONSENT

The Women’s Preventive Health Services Survey (WPHSS), sponsored by the Centers for Disease Control and Prevention (CDC), is a three-year study to examine the facilitators and barriers to receiving clinical preventive services among newly insured medically underserved women. Thank you for agreeing to share your experience with us.

We are asking you to take part in the study because program staff identified you as someone who can tell us about the screening tests you received. Each year of the study we will contact you about completing a survey. We would also like to know if there have been any gaps in health insurance coverage, problems accessing health care, and if you are getting follow-up care. Your answers are valuable to our project. There are no right or wrong answers. This interview is not meant to evaluate you. Rather, it is meant to learn about your experience with your new health insurance policy.

The survey will take about 20 – 25 minutes. There are no expected risks to participating in the survey.

The information we learn from this study will help us understand if women are getting the cancer prevention services they need. Study results will be shared with the project team at CDC.

Your participation is voluntary. You may choose not to answer any of the questions or you may choose not to participate without penalty. You can choose to stop the survey at any time for any reason.

Upon completion of this first survey, we will send you a $10 gift card. We will contact you next year to complete this survey again.

If you would like more information about this study, if you would like to withdraw from this study, or if you would like to know more about your rights as a participant, you may contact the principal investigator.

I have read the above information. I consent voluntarily to be a participant in this study.

 YES

 NO

CONTACT INFORMATION

Before we start the survey, we would like to confirm your contact information. This will allow us to mail your incentive to the right place and to contact you for future studies.

[IF ADDRESS IS KNOWN, PRELOAD AND ASK:] We have recorded the address below for you. If all is correct, please hit ‘Next’ to continue. If you need to make updates, please do so in the fields below.

[IF ADDRESS IS NOT KNOWN:] Please enter your current home address.

Street Address

Apt.#

City

State

Zip code

[IF PHONE NUMBER IS KNOWN, PRELOAD AND ASK:] We have the following phone number for you. Is this the best phone number to reach you? If so, please hit ‘Next’ to continue. If not, please enter the best phone number for you.

[IF PHONE NUMBER IS NOT KNOWN:] Please enter the best phone number where you can be reached.

-

-

Phone Number

Please provide a name of a person who can serve as a point of contact if we cannot reach you.

First Name

Last Name

Please enter your point of contact’s phone number.

-

-

Point of Contact’s Phone Number

DEMOGRAPHICS

1. What is your date of birth?

/

/

Month

Day

Year

2a. Are you of Hispanic, Latina, or Spanish origin?

			Yes				Don’t Know
			No				Refused

2b. Which of these groups represents your race? (MARK ALL THAT APPLY)

			Alaska Native or American Indian				White
			Asian				Don’t Know
			Black or African American				Refused
			Native Hawaiian or Pacific Islander

3. What is the highest grade or year of school you completed?

			Never attended school or only attended kindergarten
			Grades 1 through 8 (Elementary)
			Grades 9 through 11 (Some high school)
			Grade 12 or GED (High school graduate)
			College 1 year to 3 years (Some college or technical school)
			College 4 years or more (College graduate)
			Graduate school (Masters, Doctorate)
			Don’t Know
			Refused

4. Are you currently…? If more than one category applies, please select the best option.

			Employed for wages				A Student
			Self-employed				Retired
			Out of work for 1 year or more				Unable to work
			Out of work for less than 1 year				Don’t Know
			A Homemaker				Refused

5. Are you…?

			Married				Never been married
			Divorced				A member of an unmarried couple
			Widowed				Don’t Know
			Separated				Refused

6a. How many children less than 18 years of age live in your household?

				Number of children
			Don’t Know
			Refused

6b. How many adults, 18 years of age and older, live in your household?

				Number of adults
			Don’t Know
			Refused

6c. Are you currently pregnant?

			Yes				Don’t Know
			No				Refused

6d. Have you given birth in the past 12 months?

			Yes
			No
			Refused

7. Thinking about members of your family living in your household, what is your combined annual income, meaning the total pre-tax income from all sources earned in the past year? Please include the income of anyone you consider a member of your family living in your household.

			$0-9,999					$75,000 – 99,999
			$10,000 – 14,999					$100,000 – 199,999
			$15,000 – 19,999					$200,000 OR MORE
			$20,000 – 34,999					Don’t Know
			$35,000 – 49,999					Refused
			$50,000 – 74,999
IF NEEDED: Please answer weekly or monthly below.
			WEEKLY (Please specify)	$
			MONTHLY (Please specify)	$

8. Do you own your home, rent it, or is there some other arrangement?

			Own				Don’t Know
			Rent				Refused
			Some other arrangement

HEALTH INSURANCE STATUS

9a. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?

			Yes				Don’t Know  SKIP TO QUESTION 9e
			No  SKIP TO QUESTION 9e				Refused  SKIP TO QUESTION 9e

9b. If Yes to question 9a, what type of insurance or health care plan are you currently covered by?

			Private health insurance (i.e.,				Indian Health Service
			UnitedHealth, Aetna, Cigna, Blue Cross
			Blue Shield, etc.)				Other (Please specify)
			Medicare
							Don’t know
			Medicaid
							Refused
			Military health care
			(TRICARE/VA/CHAMP-VA)

9c. If Yes to question 9a, is this plan for yourself only or for you and your family?

			Self only plan				Don’t Know
			Family plan through you				Refused
			Family plan through spouse or				Other (Please specify)
			other family member

9d. If Yes to question 9a, about how long have you had this coverage?

			6 months or less				More than 3 years
			More than 6 months, but not				Don’t Know
			more than 1 year ago
							Refused
			More than 1 year, but not more
			than 3 years ago

9e. If No to question 9a, you are not currently covered, for what reason are you not enrolled in health insurance?

		Yes	No	Don’t Know	Refused
1	The costs are too high
2	I didn’t understand the plans that were offered
3	The plans do not cover the benefits I am looking for
4	The choice of doctors, hospitals, and other providers in the plans’ networks is too limited
5	I am still weighing my options and I am not ready to enroll
6	I would rather pay the penalty for not having health insurance
7	I do not have enough money right now
8	Other (please specify)

10. Before you had this coverage or became uninsured, what type of insurance or health care plan were you previously covered by?

			Private health insurance (i.e.,				Indian Health Service
			UnitedHealth, Aetna, Cigna, Blue
			Cross Blue Shield, etc.)				Other (Please specify)
			Medicare
							No coverage of any type
			Medicaid
							Don’t Know
			Military health care
			(TRICARE/VA/CHAMP-VA)				Refused

11a. In the past 12 months, was there any time when you did not have any health insurance?

			Yes				Don’t Know  SKIP TO QUESTION 11d
			No  SKIP TO QUESTION 11d				Refused  SKIP TO QUESTION 11d

11b. If Yes to question 11a, about how many months were you without coverage?

		Months

11c. If Yes to question 11a, what was the main reason for not having coverage?

			Could not afford cost of insurance
			You or your spouse/other family member lost job or working less hours
			You or your spouse/other family member got a job or working more
			Hours
			You or your spouse/other family member changed jobs
			Got married
			Got divorced
			Had a child
			You or your spouse/other family member got sick or injured
			Other (Please specify)
			Don’t Know
			Refused

11d. In the past 12 months, have you continued to receive any assistance with clinical services such as screening, education or follow-up tests through the [STATE’S] BCCCP?

			Yes				Don’t Know
			No				Refused

ENROLLMENT PATTERNS

PROGRAMMER: IF 9A = NO, DON’T KNOW OR REFUSED, SKIP TO QUESTION 16.

12a. How did you enroll in your current health insurance?

		Yes	No	Don’t Know	Refused
1	Website
2	Call center
3	Assistance from navigators, application assisters, certified application counselors, or community health workers
4	Assistance from an insurance agent or broker
5	Assistance from family or friends
6	Assistance from an employer
7	Assistance from a tax preparer
8	Assistance from a hospital, doctor’s office, or clinic
9	Through new job
10	Through marriage or a family member’s insurance
11	Other (please specify)

12b. We would now like to ask you about how easy or how difficult it was to enroll. First, what made it easy to enroll?

		Yes	No	Don’t Know	Refused
1	Website easy to use
2	Telephone help available
3	Translator available
4	Information easy to understand
5	Plan choices met my needs
6	In person assistance
7	Very affordable
8	Other (please specify)

12c. What made it difficult to enroll?

		Yes	No	Don’t Know	Refused
1	Tried to enroll in a plan but the website was not working
2	Website was too difficult to move through
3	Information was too difficult to understand
4	Information was not available in my native language
5	No telephone help was available
6	There were too many plan choices
7	Costs were too high
8	Other (please specify)

13a. A premium is how much you spend to have health insurance. Do you pay a premium for your health insurance?

			Yes				Don’t Know  SKIP TO QUESTION 14a
			No  SKIP TO QUESTION 14a				Refused  SKIP TO QUESTION 14a

13b. If Yes to question 13a, would you say that the cost of your premium is a financial burden to you/your family?

Yes

No

Don’t Know

Refused

14a. A deductible is the amount you have to pay before your health insurance or health coverage plan will start paying your medical bills. Do you pay a deductible for your health insurance?

			Yes				Don’t Know  SKIP TO QUESTION 15a
			No  SKIP TO QUESTION 15a				Refused  SKIP TO QUESTION 15a

14b. If Yes to question 14a, would you say that the cost of the deductible is a financial burden to you/your family?

Yes

No

Don’t Know

Refused

15a. Out-of-pocket health care costs are costs that are not covered by your health insurance plan, such as limits on the number of refills for certain drugs, the number of visits to certain specialists, or the number of days covered for certain benefits. Do you have out of pocket costs that are not covered by your health plan?

			Yes				Don’t Know  SKIP TO QUESTION 16
			No  SKIP TO QUESTION 16				Refused  SKIP TO QUESTION 16

15b. If Yes to question 15a, would you say that out of pocket health care costs are a financial burden to you/your family?

Yes

No

Don’t Know

Refused

16. Because of the amount that you (or your family) have spent on different types of health care over the last 12 months, have you (or your family) done any of the following?

		Yes	No	Don’t Know	Refused
1	Cut back on seeking health care
2	Cut back on other types of spending
3	Cut back on savings or taken money out of savings
4	Added hours at current job or took another job to help cover the cost of health care
5	Had to borrow or take on credit card debt
6	Had to declare bankruptcy
7	Made some other changes (Please specify)

17. Was there a time in the past 12 months when you needed to see a doctor or health care provider but could not because of cost?

Yes

No

Don’t Know

Refused

18. Was there a time in the past 12 months when you did not take your medication as prescribed because of cost? This could include skipping doses, taking less medicine, delaying filling a prescription, buying prescription drugs from another country, or using alternative therapies. Do not include over-the-counter medication.

			Yes				Don’t Know
			No				Refused
			No medication was prescribed

ACCESS TO PREVENTIVE HEALTH SERVICES

19. Do you have one person you think of as your personal doctor or health care provider, including your OB/GYN?

Yes

No

Don’t Know

Refused

20. What kind of place do you go to most often for healthcare services?

			Private doctor’s office or HMO				Hospital Emergency Room
			Community Health Center				Free Local Clinic
			Health Department				Don’t Know
			Family Planning Clinic				Refused
			Urgent Care/Walk-in clinic				Other (please specify)

21a. Have you had a routine health check or exam in the past 12 months? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition.

			Yes				Don’t Know  SKIP TO QUESTION 22
			No  SKIP TO QUESTION 22				Refused  SKIP TO QUESTION 22

21b. If Yes to 21a, during your last routine check-up, did staff do any of the following? (MARK ALL THAT APPLY)

		Yes	No	Don’t Know	Refused
1	Provide education
2	Provide support or counseling
3	Help you schedule an appointment
4	Help you with transportation
5	Provide a translator/translation
6	Arrange child or eldercare
7	Call to remind you of the appointment
8	Follow up with you to make sure you got your test results
9	Helped you get any follow up test or treatment needed

21c. If Yes to 21a, in the last 12 months, how often did your healthcare provider give you an easy to understand explanation about the next steps for your health questions or concerns?

			Never				Always
			Sometimes				Don’t Know
			Usually				Refused

21d. If Yes to 21a, in the last 12 months, did you feel you could trust your healthcare provider with your medical care?

			Yes, definitely				Don’t Know
			Yes, somewhat				Refused
			No

PROGRAMMER: IF 21A=YES, SKIP TO Q23.

22. If you have not had a routine health check or exam in the past 12 months, what is the main reason?

			Seldom or never get sick
			Recently moved to area
			Don’t know where to go for care
			Usual source for preventive care is no longer available
			Can’t find a provider who speaks my language
			Like to go to different places for different health needs
			Just changed insurance plans
			Don’t think preventive healthcare is important
			Other (Please specify)
			Don’t Know
			Refused

23. In the past 12 months, did you experience any of the following difficulties getting a routine check-up?

		Yes	No	Don’t Know	Refused
1	You couldn’t get through on the telephone
2	You couldn’t get an appointment soon enough
3	No one to translate
4	Once you got there, you had to wait too long to see the doctor
5	The clinic/doctor’s office wasn’t open when you got there
6	You didn’t have transportation
7	You didn’t have childcare or eldercare
8	You had trouble getting off work
9	You didn’t have insurance
10	Previous doctor is not available/moved
11	Too expensive/cost
12	Other (Please Specify)

24. In general, how satisfied are you with the health care you received at your routine check-up in the past 12 months?

			Very satisfied
			Somewhat satisfied
			Somewhat dissatisfied
			Very dissatisfied
			Don’t Know
			Refused

PARTICIPATION IN SCREENING SERVICES

25a. A mammogram is an x-ray of each breast to look for breast cancer. During the last 12 months, has your healthcare provider recommended you receive a mammogram?

Yes

No

Don’t Know

Refused

25b. Have you had a mammogram in the last 12 months?

			Yes				Don’t Know  SKIP TO QUESTION 26a
			No  SKIP TO QUESTION 26a				Refused  SKIP TO QUESTION 26a

25c. If Yes to 25b, did health care staff do any of the following related to your mammogram?

		Yes	No	Don’t Know	Refused
1	Provide education
2	Provide support or counseling
3	Help you schedule an appointment
4	Help you with transportation
5	Provide a translator/translation
6	Arrange child or eldercare
7	Call to remind you of the appointment
8	Follow up with you to make sure you got your test results
9	Help you get any follow up test or treatment needed

25d. If Yes to 25b, was it recommended for you to have follow-up tests?

			Yes				Don’t Know  SKIP TO QUESTION 26a
			No  SKIP TO QUESTION 26a				Refused  SKIP TO QUESTION 26a

25e. If Yes to 25d, did you follow the recommendation to have the follow-up tests?

			Yes				Don’t Know  SKIP TO QUESTION 25g
			No  SKIP TO QUESTION 25g				Refused  SKIP TO QUESTION 25g

25f. If Yes to 25e, how much did you pay for the follow-up tests? Please also include co-pay costs, if applicable, when answering this question.

			No cost				Don’t Know
			Less than $100				Refused
			More than $100

PROGRAMMER: AFTER 25f, GO TO QUESTION 26a.

25g. If No to 25e, what is the most important reason you did not follow the recommendation to have follow-up tests?

			No reason/never thought about it				Fear of finding cancer
			Put it off/didn’t get around to it				Other (Please specify)
			Too expensive/cost
							Don’t Know
			Worried tests would be too
			painful/unpleasant/embarrassing				Refused
			Don’t have a doctor

26a. A clinical breast exam is when a doctor, nurse, or other health professional feels the breasts for lumps. Have you had a clinical breast exam in the last 12 months?

			Yes				Don’t Know  SKIP TO QUESTION 27a
			No  SKIP TO QUESTION 27a				Refused  SKIP TO QUESTION 27a

26b. If Yes to 26a, did health care staff do any of the following related to your breast exam?

		Yes	No	Don’t Know	Refused
1	Provide education
2	Provide support or counseling
3	Help you schedule an appointment
4	Help you with transportation
5	Provide a translator/translation
6	Arrange child or eldercare
7	Call to remind you of the appointment
8	Follow up with you to make sure you got your test results
9	Helped you get any follow up test or treatment needed

27a. A Pap test is a test for cervical cancer. During the last 12 months, has your healthcare provider recommended you receive a Pap test?

Yes

No

Don’t Know

Refused

27b. Have you had a Pap test in the last 12 months?

			Yes				Don’t Know  SKIP TO QUESTION 28a
			No  SKIP TO QUESTION 28a				Refused  SKIP TO QUESTION 28a

27c. If Yes to 27b, did health care staff do any of the following related to your Pap test

		Yes	No	Don’t Know	Refused
1	Provide education
2	Provide support or counseling
3	Help you schedule an appointment
4	Help you with transportation
5	Provide a translator/translation
6	Arrange child or eldercare
7	Call to remind you of the appointment
8	Follow up with you to make sure you got your test results
9	Helped you get any follow up test or treatment needed

27d. If Yes to 27b, was it recommended for you to have follow-up tests?

			Yes				Don’t Know  SKIP TO QUESTION 28a
			No  SKIP TO QUESTION 28a				Refused  SKIP TO QUESTION 28a

27e. If Yes to 27d, did you follow the recommendation to have the follow-up tests?

			Yes				Don’t Know  SKIP TO QUESTION 27g
			No  SKIP TO QUESTION 27g				Refused  SKIP TO QUESTION 27g

27f. If Yes to 27e, how much did you pay for the follow-up tests? Please also include co-pay costs, if applicable, when answering this question.

			No cost				Don’t Know
			Less than $100				Refused
			More than $100

PROGRAMMER: AFTER 27f, GO TO QUESTION 28a.

27g. If No to 27e, what is the most important reason you did not follow the recommendation

to have follow-up tests?

			No reason/never thought about it				Fear of finding cancer
			Put it off/didn’t get around to it				Other (Please specify)
			Too expensive/cost
			Worried tests would be too				Don’t Know
			painful/unpleasant/embarrassing
			Don’t have a doctor				Refused

28a. A home blood stool test is a test to determine whether you have blood in your stool or bowel movement. The blood stool test is done at home using a kit. You use a stick or brush to obtain a small amount of stool at home and send it back to the doctor or lab. Has your healthcare provider recommended you receive a blood stool test in the last 12 months?

Yes

No

Don’t Know

Refused

28b. Have you had this test using a home kit in the last 12 months?

			Yes				Don’t Know  SKIP TO QUESTION 29a
			No  SKIP TO QUESTION 29a				Refused  SKIP TO QUESTION 29a

28c. If Yes to 28b, did health care staff do any of the following related to your results of this

home kit test?

		Yes	No	Don’t Know	Refused
1	Provide education
2	Provide support or counseling
3	Help you schedule an appointment
4	Help you with transportation
5	Provide a translator/translation
6	Arrange child or eldercare
7	Call to remind you of the appointment
8	Follow up with you to make sure you got your test results
9	Helped you get any follow up test or treatment needed

28d. If Yes to 28b, was it recommended for you to have follow-up tests?

			Yes				Don’t Know  SKIP TO QUESTION 29a
			No  SKIP TO QUESTION 29a				Refused  SKIP TO QUESTION 29a

28e. If Yes to 28d, did you follow the recommendation to have the follow-up tests?

			Yes				Don’t Know  SKIP TO QUESTION 28g
			No  SKIP TO QUESTION 28g				Refused  SKIP TO QUESTION 28g

28f. If Yes to 28e, how much did you pay for the follow-up tests? Please also include co-pay costs, if applicable, when answering this question.

			No cost				Don’t Know
			Less than $100				Refused
			More than $100

PROGRAMMER: AFTER 28f, GO TO QUESTION 29a.

28g. If No to 28e, what is the most important reason you did not follow the recommendation to have follow-up tests?

			No reason/never thought about it				Fear of finding cancer
			Put it off/didn’t get around to it				Other (Please specify)
			Too expensive/cost
			Worried tests would be too				Don’t Know
			painful/unpleasant/embarrassing
							Refused
			Don’t have a doctor

29a. Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the colon for signs of cancer or other health problems. Has your healthcare provider recommended you receive a sigmoidoscopy or colonoscopy in the last 12 months?

Yes

No

Don’t Know

Refused

29b. Have you had either a sigmoidoscopy or colonoscopy in the last 12 months?

			Yes				Don’t Know  SKIP TO QUESTION 30
			No  SKIP TO QUESTION 30				Refused  SKIP TO QUESTION 30

29c. If Yes to 29b, did health care staff do any of the following related to your sigmoidoscopy or colonoscopy?

		Yes	No	Don’t Know	Refused
1	Provide education
2	Provide support or counseling
3	Help you schedule an appointment
4	Help you with transportation
5	Provide a translator/translation
6	Arrange child or eldercare
7	Call to remind you of the appointment
8	Follow up with you to make sure you got your test results
9	Helped you get any follow up test or treatment needed

29d. If Yes to 29b, was it recommended for you to have follow-up tests?

			Yes				Don’t Know  SKIP TO QUESTION 30
			No  SKIP TO QUESTION 30				Refused  SKIP TO QUESTION 30

29e. If Yes to 29d, did you follow the recommendation to have the follow-up tests?

			Yes				Don’t Know  SKIP TO QUESTION 29g
			No  SKIP TO QUESTION 29g				Refused  SKIP TO QUESTION 29g

29f. If Yes to 29e, how much did you pay for the follow-up tests? Please also include co-pay costs, if applicable, when answering this question.

			No cost				Don’t Know
			Less than $100				Refused
			More than $100

PROGRAMMER: AFTER 29f, GO TO QUESTION 30.

29g. If No to 29e, what is the most important reason you did not follow the recommendation to have follow-up tests?

			No reason/never thought about it				Fear of finding cancer
			Put it off/didn’t get around to it				Other (Please specify)
			Too expensive/cost
			Worried tests would be too				Don’t Know
			painful/unpleasant/embarrassing
							Refused
			Don’t have a doctor

30. Have you had your blood pressure checked by a doctor, nurse, pharmacist, or other health professional in the last 12 months?

Yes

No

Don’t Know

Refused

31. Have you had a flu vaccination (shot or nasal spray) in the last 12 months?

Yes

No

Don’t Know

Refused

32. Have you had a test for high blood sugar or diabetes within the last 12 months?

Yes

No

Don’t Know

Refused

33. In terms of the screening services you have received, how satisfied are you with your health care provider?

			Very satisfied
			Somewhat satisfied
			Somewhat dissatisfied
			Very dissatisfied
			Don’t Know
			Refused

HEALTH OUTCOMES

34. Would you say that in general your health is?

			Excellent
			Very Good
			Good
			Fair
			Poor
			Don’t Know
			Refused

35. Do you have any medical conditions that require you to visit a doctor or health care provider (including specialists) regularly (e.g., quarterly, monthly, weekly)?

Yes

No

Don’t Know

Refused

36a. Have you ever been diagnosed with cancer?

Yes

No

Don’t Know

Refused

36b. If yes to 36a, which of the following cancers have you been diagnosed with?

		Yes	No	Don’t Know	Refused
1	Breast cancer
2	Cervical cancer
3	Colorectal cancer
4	Lung cancer
5	Ovarian cancer
6	Skin cancer
7	Blood cancer
8	Bone cancer
9	Lymphoma
10	Other (Please Specify)

37. This last question is about your family history of cancer. Has your biological father, mother, or sibling(s) ever been diagnosed with any of the following cancers:

		Yes	No	Don’t Know	Refused
1	Breast cancer
2	Cervical cancer
3	Colorectal cancer
4	Lung cancer
5	Ovarian cancer
6	Prostate cancer
7	Skin cancer
8	Blood cancer
9	Bone cancer
10	Lymphoma
11	Other (Please Specify)

THANK YOU FOR PARTICIPATING IN THIS SURVEY!

We appreciate your time in providing us with this important information.

We will send out this survey to you again next year for follow-up purposes.

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