Form 0920-23IE Caregiver Survey_English

Form approved OMB # 0920-####

Exp. date MM/DD/YYYY

ATTACHMENT 4A

Caregiver Survey (online, English)

Public reporting burden of this collection of information is estimated to average of 15 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-####).

For Caregivers of Patients with Breast Cancer

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

For Caregivers of Patients with Cervical Cancer

If caregiver selects “Did not encounter any issues”, will see:

For Caregivers of Patients with Colorectal Cancer

If the caregiver selects any problems, they will see:

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