Form 0920-23IE Wave 1 Survivor Survey_English

Form approved OMB # 0920-####

Exp. date MM/DD/YYYY

ATTACHMENT 2A

Wave 1 Survey (online, English)

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

Cancer Type Fill

Depending on what type of cancer the respondent has (breast, cervical, or colorectal), the type will fill automatically on a number of questions. For example, “What was your marital status when you were first diagnosed with breast cancer?” We’ve included screenshots of each type of diagnosis for the whole survey – respondents will only answer one version of the survey in their preferred language, English or Spanish.

For Respondents with Breast Cancer

If patient selects problems, they will see:

If they did not encounter any problems, they will see:

If patients selects any problems, they will see:

If they select “Did not encounter any problems”, they will see:

For Respondents with Cervical Cancer

If a patient selects problems, they will see this:

If a patient responds that they had no problems, they will see the following question:

If patient selects “Did not encounter any problems”, they will be shown this question:

For Respondents with Colorectal Cancer

If patient selects problems, they will see:

If they select “Did not encounter any issues”, they will see:

If the patient selects problems, they will see:

If patient selects “Did not encounter any problems”, they will see: