Attachment 04c_Provider Survey_Paper_English

Form approved

OMB # 0920-####

Exp. date MM/DD/YYYY

ATTACHMENT 4c

Provider Survey:

Paper, English

Section 1: Prostate Cancer Screening Practices

First, please tell us about your screening practices for prostate cancer.

1. Which approach best describes your practice regarding prostate cancer screening with age-appropriate men who have no other risk factors and are otherwise candidates for screening? (Check one)

• I generally order the PSA test without discussing the possible harms and benefits with the patient.

• I generally discuss the possible harms and benefits of screening with the patient, and then recommend the test.

• I generally discuss the possible harms and benefits of screening with the patient, and then let him decide whether or not to have the test.

• I generally discuss the possible harms and benefits of screening with the patient, and then recommend against the test.

• I generally do not order the PSA test nor discuss the possible harms and benefits with the patient.

• Other (please specify)

Section 2: Attitudes Toward Prostate Cancer Screening

We would like to know your views on prostate cancer screening. Some of these statements are about prostate cancer screening in general, while others ask specifically about prostate specific antigen (PSA).

Select one response for each statement	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
The benefits of prostate cancer screening outweigh the risks.
Discussing harms and benefits of prostate cancer screening causes unnecessary anxiety in my patients.
I do not have time to discuss the harms and benefits of prostate cancer screening with my patients.
Patients have a right to know the implications of prostate cancer screening before they are screened.
Patients should be told that it has yet to be proven that prostate cancer screening saves lives.
I have lost patients to prostate cancer who might have been saved if they had been screened with PSA.
I have lost close family members or friends to prostate cancer.
There have been times when I have regretted ordering a PSA test for a patient.
I have wondered if treatment for prostate cancer is worth it for some patients.
There is no need to educate patients about prostate cancer screening because in general they want to be screened.
My patients frequently request the PSA test.
There is clear evidence that prostate cancer screening saves lives.
My clinical experience is more important than research studies in how I handle screening.
The scientific evidence does not support routine screening for prostate cancer.
Prostate cancer screening is a standard of care in my community.
I would describe myself as someone who practices evidence-based medicine.
Not ordering a PSA test puts a physician at risk for malpractice liability.

Section 3: Demographic Characteristics

Finally, tell us about yourself and your practice.

1. Total years in practice: ____ years

2. Sex:

• Male

• Female

• I prefer not to say

3. Practice type: (Select all that apply)

• Solo practice

• Two-person partnership

• Family practice group

• Multispecialty group

• Academic practice (residency program, faculty practice)

• Other (please specify)

Thank you for your time.

Public reporting burden of this collection of information is estimated to average 10 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-####).