Post-Clinic Visit Survey_Paper_English

Form approved

OMB # 0920-####

Exp. date MM/DD/YYYY

ATTACHMENT 10g

Post-Clinic Visit Survey:

Paper, English

Thank you for participating in this study, where we hope to learn whether different types of decision aid tools can help men make more informed decisions about prostate cancer screening. Your completion of this form is completely voluntary, and your responses are confidential. By completing the form, you are giving your consent to participate in this assessment.

Section 1: Prostate Cancer Knowledge - Modified PrCA Knowledge Scale (Owens et al., 2019)

For this first section, we’d like to get a sense of your prostate cancer knowledge now that you have reviewed the decision aid and had a visit with your health care provider. If you are unsure of the answer, please select the “Not sure” response for that question.

Anatomy and Function

1. The prostate gland is a reproductive organ located below the bladder.

• True

• False

• Not sure

2. The prostate gland makes some of the fluid that’s part of semen.

• True

• False

• Not sure

Risk Factors

3. Older men are more likely to get prostate cancer.

• True

• False

• Not sure

4. More Black or African American men are diagnosed with prostate cancer than White men.

• True

• False

• Not sure

5. Men who have fathers or brothers with prostate cancer are more likely to get prostate cancer than those who do not.

• True

• False

• Not sure

6. Who do you think is more likely to get prostate cancer?

• White men

• Black or African American men

• Hispanic or Latino men

• Asian men

• Race or ethnicity is not a factor

• Not sure

7. Who do you think is more likely to get prostate cancer?

• A man whose father has had prostate cancer

• A man whose father has not had prostate cancer

• It doesn’t make any difference

• Not sure

Screening

8. A prostate-specific antigen (PSA) blood test can be done to check for prostate cancer.

• True

• False

• Not sure

9. A digital rectal exam or DRE can be done to check for prostate cancer.

• True

• False

• Not sure

10. The only way a man can know for sure if he has prostate cancer is to have a prostate biopsy.

• True

• False

• Not sure

11. A prostate biopsy is when a blood test is used to check for proteins in the blood.

• True

• False

• Not sure

12. Neither the PSA nor DRE are 100% accurate.

• True

• False

• Not sure

Warning Signs

13. A man can have prostate cancer and have no symptoms.

• True

• False

• Not sure

Section 2: Decisional Conflict Traditional Decisional Conflict Scale (Garvelink et al., 2019 and O’Connor, 1995a)

As it relates to prostate cancer screening, after meeting with your health care provider, please indicate your agreement with each statement, using either strongly agree, agree, neither, disagree, or strongly disagree.

Question	Strongly Agree	Agree	Neither	Disagree	Strongly Disagree
I know which prostate cancer screening options are available to me.
I know the benefits of each option.
I know the risks and side effects of each option.
I am clear about which benefits matter most to me.
I am clear about which risks and side effects matter most.
I am clear about which is more important to me (the benefits or the risks and side effects).
I have enough support from others to make a choice about prostate cancer screening.
I am choosing without pressure from others.
I have enough advice to make a choice.
I am clear about the best choice for me.
I feel sure about what to choose.
This decision is easy for me to make.
I feel I have made an informed choice.
My decision shows what is important to me.
I expect to stick with my decision.
I am satisfied with my decision.

Section 3: Autonomous Decision Making - Control Preferences Scale (Degner et al., 1997)

1. Please check the response that best describes how you were involved in making decisions about screening for prostate cancer.

• I was less involved than I wanted to be.

• I was as involved as I wanted to be.

• I was more involved than I wanted to be.

Section 4: Shared Decision Making - Shared Decision-Making Process Survey (Valentine et al., 2021 and Fowler et al., 2021)

Please answer the following questions about what happened when you talked with your health care provider about screening for prostate cancer.

1. Did you discuss prostate cancer screening with your provider?

• Yes

• No (if no, skip to section 6)

2. If yes, how much did you and your health care provider talk about the reasons you might want to have prostate cancer screening?

• A lot

• Some

• A little

• Not at all

3. How much did you and your health care provider talk about the reasons you might not want to have prostate cancer screening?

• A lot

• Some

• A little

• Not at all

4. Did your health care provider talk about a PSA blood test as something that you should seriously consider?

• Yes

• No

5. Did your health care provider ask if you wanted to have prostate cancer screening?

• Yes

• No

Section 5: Time Spent with Provider

Please answer the following questions about the amount of time spent talking with your health care provider about the PSA test.

1. Did you talk with your health care provider about the PSA test?

• Yes

• No [skip sub question 2 and move on to section 6]

2. About how many minutes did you spend with your health care provider discussing the PSA test? (open-ended)

Section 6: Screening Behavior

Please answer the following question about getting a PSA test.

1. Did you get a blood test to screen for prostate cancer?

• Yes

• No, but I intend to

• No, and I do not intend to

Section 7: Informational Materials Used in Making Screening Decision

1. Please describe any informational tools or materials you have read or used to help you make a decision about prostate cancer screening. (open-ended)

Section 8: Gift Code

Thank you for completing this survey. Your $25 Amazon gift code is <GIFT_CODE>.

The code is a unique number you can use to purchase items online at Amazon.com. You may enter the code online when you are ready to make a purchase at Amazon.com. There is no expiration date.

Would you like this gift code emailed to you as well with instructions about how to use it?

01 Yes, please email it (note email address)

02 No need to email it

Section 9: Closing

Thank you for your responses to this survey.

We greatly appreciate your participation in the study on prostate cancer screening. Your participation in the various surveys and discussions have helped us gather information that will provide a deeper understanding of how well interactive tools and educational materials will help men make decisions about prostate cancer screening.

We assure you that your responses will be kept confidential and will not be shared outside of the study. Summaries of survey results and discussions will not be linked to your name or clinic when shared with CDC and/or when published in a professional journal.

If you have any questions, please contact the project manager, Danielle Nielsen at [email protected].

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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-####).