0920-23IE Wave 1 Survivor Survey_Spanish

Form approved

OMB # 0920-####

Exp. date MM/DD/YYYY

Attachment 2c.

Wave 1 Survivor Survey (online, Spanish)

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 respondents select problems, they will see:

If respondents select that they did not encounter problems, they will see:

If respondents select problems, they will see:

If respondents select that they did not experience any problems, they will see:

If respondents select problems, they will see:

If respondents select that they didn’t have any problems, they will see:

For Respondents with Cervical Cancer

If respondents select problems, they will see:

If respondents select that they didn’t encounter any problems, they will see:

If respondents select problems, they will see:

If respondents select that they did not experience any problems, they will see:

If respondents select problems, they will see:

If respondents select that they didn’t have any problems, they will see:

For Respondents with Colorectal Cancer

If respondents select problems, they will see:

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

If respondents select problems, they will see:

If respondents select that they did not experience any problems, they will see:

If respondents select problems, they will see:

If respondents select that they didn’t have any problems, they will see:

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-####).