Form 0920-18AWP Follow-up Screener

Form Approved

OMB No. 0000-0000

Exp. Date 00/00/201X

Attachment 6b:

Follow-Up Screener Survey

Public reporting burden of this collection of information is estimated to average 2 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 30333; ATTN: PRA (0920-XXXX).

1. AGE (NHIS_2015 - AIDAGE). How old are you?

(0-120) Age in years

<Programmer: If AGE <18, ineligible.>

2. SEX (HINTS 4, CYCLE 4 - J1). Are you male or female?

Male

Female

Prefer not to answer

<Programmer: If respondent recruited by email, skip to Q8>.

3. The following questions refer to genetic TESTING for cancer risk. That is, testing your blood to see if you carry genes which may predict a greater chance of developing cancer at some point in your life. This does NOT include tests to determine if you have cancer now.

POSSIBLETESTING (NHIS 2015 -GTPOSS1). Have you ever discussed the possibility of getting a genetic test for cancer risk with a doctor or other health professional?

RECOMMENDTESTING (NHIS 2015 - BL1). Has a medical doctor ever recommended that you get a genetic test for cancer risk?

RECEIVEDTESTING (NHIS 2015 - GTGRISK). Have you ever had a genetic test to determine if you are at greater risk of developing cancer in the future?

<Programmer: This item will be included in a small grid with Yes, No, and DK/Prefer not to answer categories.>

<Programmer: If RECEIVEDTESTING = Yes then continue to High Risk Survey. Else, ineligible.>

“NOT ELIGIBLE FOR THE SURVEY” SCREEN

Unfortunately, you are not eligible to participate in this survey.

Thank you for your interest.

<PROGRAMMER: Please provide an “exit the questionnaire” button.>