Grantee Survey

5/14/18

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

Cancer Survivorship Assessment

Web-based Grantee Survey

Public reporting burden of this collection of information is estimated to average 20 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 30329; ATTN: PRA (0920-XXXX).

CANCER SURVIVORSHIP ASSESSMENT WEB-BASED SURVEY

Introduction

CDC has funded RTI to assess the DP15-1501 Cancer Survivorship program. As part of this assessment, RTI is administering a web-based survey to NCCCP DP15-1501 grantees and their partners. The purpose of the survey is to gather your perspectives on:

• increasing utilization of surveillance data to inform program planning,

• planning, implementing, and sustaining evidence-based strategies to increase knowledge of cancer survivor needs, and

• enhancing partnerships that can facilitate and broaden program reach

We’d also like your perspective on the challenges, facilitators, and lessons learned with regard to implementing these activities.

The survey should take less than 20 minutes to complete. Your answers will not be linked to your name and there are minimal risks to you from participation. We will use some quotes in reports, but quotes will not be attributed to an individual or his/her organization. We want to assure you that we will not quote you by name. All of the survey data will be kept secure on RTI’s network.

Your insights will be used by CDC to improve efforts to support NCCCP programs in implementing evidence-based and promising strategies to improve cancer survivorship care.

This research protocol has been reviewed by RTI’s Institutional Review Board (IRB).

Clicking on the ‘Next’ button below indicates that you have read the above information and you agree to participate in the survey.

Surveillance Data

1. Have you worked on supporting the use of surveillance data (e.g., Behavioral Risk Factor Surveillance System [BRFSS], Electronic Health Records) among providers or coalition members?

 Yes

 No  Skip to Question 14

2. In what ways are you using surveillance data to inform cancer survivorship interventions (program planning)? Select all that apply.

 Identify target populations

 Identify cancer survivors’ needs

 Populate Survivorship Care Plans

 Monitor survivorship outcomes

 Other, please describe: ___________

3. Have you been involved in efforts to add the Cancer Survivorship module to your state’s Behavioral Risk Factor Surveillance System (BRFSS)?

 Yes

 No  Skip to Question 6

4. Please select your state’s approach to adopting the Cancer Survivorship module.

 My state adopted the entire Cancer Survivorship module at the onset.

 My state is doing a phased adoption of the Cancer Survivorship module, starting with a subset of questions.

 My state has adopted a subset of questions with no current plans to add remaining questions.

□ My state has not adopted any Cancer Survivorship module questions.

5. Please indicate which of the following questions from the Cancer Survivorship module were included in your state’s most recent BRFSS. Select all that apply.

 All of the questions in the module were included.

 Question 1. How many different types of cancer have you had?

 Question 2. At what age were you told that you had cancer?

 Question 3. What type of cancer was it?

 Question 4. Are you currently receiving treatment for cancer? By treatment, we mean surgery, radiation therapy, chemotherapy, or chemotherapy pills.

 Question 5. What type of doctor provides the majority of your health care?

 Question 6. Did any doctor, nurse, or other health professional EVER give you a written summary of all the cancer treatments that you received?

 Question 7. Have you EVER received instructions from a doctor, nurse, or other health professional about where you should return or who you should see for routine cancer check-ups after completing your treatment for cancer?

 Question 8. Were these instructions written down or printed on paper for you?

 Question 9. With your most recent diagnosis of cancer, did you have health insurance that paid for all or part of your cancer treatment?

 Question 10. Were you EVER denied health insurance or life insurance coverage because of your cancer?

 Question 11. Did you participate in a clinical trial as part of your cancer treatment?

 Question 12. Do you currently have physical pain caused by your cancer or cancer treatment?

 Question 13. Is your pain currently under control?

6. Have you been involved in efforts to use surveillance data (e.g. cancer registry data) in Survivorship Care Plans?

 Yes

 No  Skip to Question 8

7. In what ways have you helped health systems commit to incorporating surveillance data (e.g. cancer registry data) into Survivorship Care Plans (SCPs)? Select all that apply.

 Meeting with providers to get buy-in

 Meeting with hospital administrators to get buy-in

 Coordinating a formal training for providers

 Coordinating a formal training for hospital administrators

 Providing on-site technical assistance

 Providing educational materials/template to providers that shows how to incorporate

surveillance data into SCPs

 Other:________________________________________________

8. Have you been involved in efforts to use individual data (e.g. electronic health records) in Survivorship Care Plans?

 Yes

 No  Skip to Question 10

9. In what ways have you helped health systems commit to incorporating individual data (e.g., electronic health records) into Survivorship Care Plans (SCPs)? Select all that apply.

 Meeting with providers to get buy-in

 Meeting with hospital administrators to get buy-in

 Coordinating a formal training for providers

 Coordinating a formal training for hospital administrators

 Providing on-site technical assistance

 Providing educational materials/template to providers that shows how to incorporate

individual data into SCPs

 Other:________________________________________________

10. What other data have you incorporated into Survivorship Care Plans (aside from cancer registry and EHR)?

 None

 Other:________________________________________________

11. What percentage of providers (e.g., physicians, nurses) in your state do you estimate use Electronic Health Record data to populate Survivorship Care Plans?

 0% (None)

 1-25%

 26-50%

 51-75%

 76-99%

 100%

 Don’t know

12. What percentage of providers (e.g., physicians, nurses) do you estimate use cancer registry data to populate Survivorship Care Plans?

 0% (None)

 1-25%

 26-50%

 51-75%

 76-99%

 100%

 Don’t know

13. What percentage of Survivorship Care Plans in your state are generated using data (e.g., cancer registry, electronic health records)?

 0% (None)

 1-25%

 26-50%

 51-75%

 76-99%

 100%

 Don’t know

Communication, Education and Training

14. Have you conducted any provider education or trainings?

 Yes

 No  Skip to Question 18

15. About how many providers have you contacted to participate in education or training opportunities? [open text]

16. Of the providers you’ve contacted, about how many participated in your education opportunities? [open text]

17. Please indicate whether you have participated in or organized any of the following educational / training opportunities for providers.

	Yes	No
National Cancer Survivorship Resource Center’s (NCSRC’s) E-learning series		
In-house presentation during clinical staff meetings		
In-house presentation during grand rounds		
Other:__________________________________________		

18. What types of communication activities have you implemented for providers? Select all that apply.

 Communication campaign materials

 Email updates/newsletters

 In-person patient navigation training

 Independently developed education materials

 Printed materials such as fact sheets or educational one-pagers

 Promoting the e-learning series and the use of Survivorship Care Plans (e.g., via one-on-one meetings, presentations at staff meetings)

 Social media

 Webinars or other CME learning activities

 Other:_____________________________________

19. What types of communication activities have you done to educate cancer survivors about Survivorship Care Plans? Select all that apply.

 Email updates/newsletters

 One-on-one meetings

 Phone calls

 Printed materials

 Social media

 Webinars

 Other:____________________________________

20. Have you contributed to the development of any of the following educational resources for cancer survivors?

	Yes	No
Information about follow-up care or screenings		
Information about emotional support		
Information about mental health
Information about physical health (e.g., nutrition, exercise, side effects from treatment)		
Information about sexual health (e.g., intimacy, fertility)		
Information about work concerns / financial support / health insurance coverage		
Information about using Survivorship Care Plans		
Other:__________________________________________		

Enhanced Partnerships

21. What type of new patient populations are you able to reach through your work with partners? Select all that apply.

 Adolescent / young adult

 African American

 Asian

 At-risk due to family history

 Disabled

 Hispanic

 LGBT

 Low-income

 Metastatic

 Native American / American Indian

 Pediatric

 Rural

 Seniors (age 65+ years)

 Veterans

 Other:_____________________________________________________

22. Because of partner collaborations, has your reach expanded to any of the following cancer survivor groups? Select all that apply.

 No expansion resulted from collaborations

 Breast

 Colorectal

 Lung

 Melanoma

 Prostate

 Ovarian/cervical (gynecological)

 Other:_______________________________________________

Challenges and Facilitators

23. What are some key factors that have led to successful partnerships with other DP15-1501 grantees (e.g., history of working together, common goals, common target audience/patient population, partners’ thought leadership/subject matter expertise)? [open text]

24. What are some key factors that have led to successful partnerships with external partners (e.g., history of working together, physical proximity of offices, common goals, common target audience/patient population, partners’ thought leadership/subject matter expertise)? [open text]

25. What have been the primary challenges in your partnerships with other DP15-1501 grantees (e.g., communication, competing priorities/interests, lack of common goal, staffing turnover, time commitment)? [open text]

26. What have been the primary challenges in your partnerships with external partners (e.g., communication, competing priorities/interests, lack of common goal, staffing turnover, time commitment)? [open text]

Respondent Background

27. In what state are you located? [Drop-down list: Indiana, Kansas, Louisiana, Michigan, South Dakota, Washington]

28. Are you employed by your state’s cancer registry?

 Yes

 No

29. What is your role at your organization?

[Drop-down list: DP15-1501 program coordinator; DP15-1501 program manager; Other:__________________]

THANK YOU FOR YOUR TIME!

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