Wave 1 Survivor Survey_paper_English

Form approved

OMB # 0920-####

Exp. date MM/DD/YYYY

Attachment 2b.

Wave 1 Survivor Survey (paper, English)

CDC APHIR Barriers Along Cancer Continuum – W1 Survivor Survey

Preload variables:

• CANC_TYPE (breast/cervical/colorectal)

• STATE_MEDICAID (Medicaid/Medi-Cal [for California]; Medicaid/North Carolina Medicaid [for NC]; Medicaid [for Texas]

Intro.

Thank you for agreeing to participate in this study. This survey will take you about 20 minutes to complete. After you submit the survey, you will receive a $40 check or electronic gift card as a token of appreciation for your time.

A goal of this study is to collect information about barriers you may have faced along the cancer continuum – from screening to diagnosis and treatment.

This survey includes questions on several topics. For example, you’ll be asked about the type of cancer you had, how old you were at diagnosis, and whether you had insurance. Some of these questions ask you to think back to events that may have occurred a few years ago.

Although the answers may be hard to remember, please do the best you can. There are no right or wrong answers to any of these questions. You should just report what you have been through as an individual diagnosed with or living with cancer.

Participation in this study is voluntary. Questions answered in this study will not affect your health care. You can skip any question you do not want to answer. Just go on to the next question. You may exit the survey at any time. You may also complete the survey in multiple sittings; your answers will be saved. Joining this study has minimal risks. Some of the questions on the survey may be upsetting, but you don’t have to answer them. Protections are in place to keep your data as safe as possible.

{PAGE BREAK}

MODULE A: DEMOGRAPHICS

A1. When you were diagnosed, what was the stage of your [CANC_TYPE] cancer?

1. Stage 0

2. Stage 1

3. Stage 2

4. Stage 3

5. Stage 4

88. Don’t know / can’t remember

{PAGE BREAK}

A2. What is your biological sex? This is a category that is based upon your original birth certificate.

1. Male

2. Female

3. Prefer not to answer

{PAGE BREAK}

A3. How old are you?

1. 21-24 years old

2. 25–29 years old

3. 30–34 years old

4. 35–39 years old

5. 40–44 years old

6. 45–49 years old

7. 50–54 years old

8. 55–59 years old

9. 60–64 years old

10. 65–69 years old

11. 70–74 years old

12. 75 years old or older

{PAGE BREAK}

{PAGE BREAK}

A5. What is your race and/or ethnicity? Select all that apply.

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Hispanic or Latino

5. Middle Eastern or North African

6. Native Hawaiian or Other Pacific Islander

7. White

8. Other [please specify]: [OPEN FIELD IF SELECTED]

88. Don’t know

99. Prefer not to answer

{PAGE BREAK}

A6. What was your marital status when you were first diagnosed with [CANC-TYPE] cancer?

1. Never married

2. Married

3. Living together with a partner as an unmarried couple / cohabitating

4. Widowed

5. Separated or divorced

A6a. What is your current marital status?

1. Never married

2. Married

3. Living together with a partner as an unmarried couple / cohabitating

4. Widowed

5. Separated or divorced

{PAGE BREAK}

A7. What was your employment status when you were first diagnosed with [CANC-TYPE] cancer?

1. Employed for pay (including self-employed) – 40 or more hours per week

2. Employed for pay (including self-employed) – Less than 40 hours per week

3. Retired

4. Homemaker

5. Student

6. Out of work for 1 year or more

7. Out of work for less than 1 year

8. Unable to work (e.g., due to disability, work authorization)

{PAGE BREAK}

A7a. What is your current employment status?

1. Employed for pay (including self-employed) – 40 or more hours per week

2. Employed for pay (including self-employed) – Less than 40 hours per week

3. Retired

4. Homemaker

5. Student

6. Out of work for 1 year or more

7. Out of work for less than 1 year

8. Unable to work (e.g., due to disability, work authorization)

{PAGE BREAK}

A8. What was your total household income in 2021?

1. Less than $20,000

2. $20,001–$40,000

3. $40,001–$60,000

4. $60,001–$80,000

5. $80,001–$100,000

6. $100,001–$120,000

7. More than $120,000

88. Don’t know

{PAGE BREAK}

A9. What was your health insurance status when you were first diagnosed with [CANC-TYPE] cancer? Please select all that apply.

1. No insurance

2. Lapse in coverage

3. Private health insurance (purchased on your own or from your job or from your spouse’s / partner’s / parent’s job)

4. [STATE_MEDICAID]

5. Medicare/Medicare Advantage

6. Military (Tricare, Champ-VA, or some other military insurance)

7. Other [please specify]: [OPEN FIELD IF SELECTED]

{PAGE BREAK}

A9a. What is your current health insurance status? Please select all that apply.

1. No insurance

2. Lapse in coverage

3. Private health insurance (purchased on your own or from your job or from your spouse’s / partner’s / parent’s job)

4. [STATE_MEDICAID]

5. Medicare/Medicare Advantage

6. Military (Tricare, Champ-VA, or some other military insurance)

7. Other [please specify]: [OPEN FIELD IF SELECTED]

{PAGE BREAK}

A10. What is the highest level of school that you completed?

1. Elementary or middle school

2. 9th –12th grade but not a high school graduate

3. High school graduate or GED

4. Some college or technical school

5. College graduate

6. Post-graduate or professional degree

{PAGE BREAK}

A11. [NUMERIC] What was your zip code at the time of your [CANC_TYPE] cancer diagnosis?

[OPEN – ALLOW 5-DIGIT ZIP CODE]

777777. I lived in multiple zip codes around the time of my cancer diagnosis.

888888. Don’t know

A11_SPEC: [SHOW IF A11=777777] Please enter the zip codes where you lived.

1. [OPEN – ALLOW 5-DIGIT ZIP CODE]

2. [OPEN – ALLOW 5-DIGIT ZIP CODE]

3. [OPEN – ALLOW 5-DIGIT ZIP CODE]

{PAGE BREAK}

A12. Which best describes your home at the time of your diagnosis?

1. A one-family house detached from any other house (including mobile homes) 

2. A one-family house attached to one or more houses (e.g., townhome, duplex) 

3. An apartment building, apartment complex, or condo 

4. I did not have stable housing (staying in a hotel, in a shelter, living outside on the street or in a park, etc.).

5. Other (please specify):  

{PAGE BREAK}

Think about your household, which includes everyone who lives with you.

A13. Please indicate whether the following statements are often true, sometimes true, or never true.

“Within the past 12 months, we worried whether our food would run out before we had money to buy more.”

1. Often true

2. Sometimes true

3. Never true

A14. “Within the past 12 months, the food we bought just didn’t last and we didn’t have money to get more.” 

1. Often true

2. Sometimes true

3. Never true

{PAGE BREAK}

MODULE B: HEALTH BACKGROUND

B1. Before your [CANC_TYPE] cancer diagnosis, what condition(s) had you been diagnosed with? Select all that apply.

1. Arthritis, rheumatism, or gout

2. Benign tumors or cysts

3. Cancers other than [CANC_TYPE] cancer

4. Chronic pain

5. Circulation problems (including blood clots)

6. Dementia or Alzheimer’s

7. Depression, anxiety, or emotional problem

8. Diabetes

9. Epilepsy or seizures

10. Fibromyalgia or lupus

11. Gastrointestinal conditions or disorders

12. Hearing problem

13. Heart problem

14. Hernia

15. Hypertension or high blood pressure

16. Kidney, bladder, or renal problems

17. Lung or breathing problem (e.g., asthma and emphysema)

18. Migraine headaches (not just headaches)

19. Multiple Sclerosis (MS) or Muscular Dystrophy (MD)

20. Osteoporosis or tendinitis

21. Parkinson’s disease or other tremors

22. Stroke

23. Thyroid problems or Graves’ disease

24. Ulcer

25. Vision problem or problem seeing

26. Weight problem

27. Other impairment or problem - Please specify one: [SHOW IF SELECTED – OPEN]

28. None of the above [EXCLUSIVE SELECT]

{PAGE BREAK}

B2. [IF A2=2] Have you had a hysterectomy?

1. Yes, full hysterectomy

2. Yes, partial hysterectomy

3. Yes, don’t know if full or partial hysterectomy

4. No

{PAGE BREAK}

B3. Have you ever tested positive for COVID-19? Select all that apply.

1. No

2. Yes, before my cancer diagnosis.

3. Yes, during my cancer treatment.

4. Yes, after my cancer treatment.

B3a. [SHOW IF B3=2, 3, OR 4] Have you ever been hospitalized due to COVID-19? 

1. No

2. Yes

{PAGE BREAK}

B4. Is there a doctor’s office, clinic, health center, or other place where you usually go if you are sick or need advice about your health (regular, non-cancer-related care)? This does not include care received in Emergency Rooms (ER), urgent care centers, or drug/grocery store clinics.

1. Yes

2. No

{PAGE BREAK}

MODULE C: COLORECTAL

[IF A3 = 6, 7, 8, 9, 10, 11, 12 CONTINUE, ELSE GOTO D1]

C1. The next questions are about colorectal cancer screening tests.

C2. Have you ever had a test to check for colorectal cancer before your diagnosis?	Yes	No
C2_1. Stool test, except Cologuard [Includes several types of blood stool or occult blood test, fecal immunochemical or FIT test. You use a kit at home to collect a small amount of stool and send it back to the doctor or lab.]
C2_2. Cologuard [Cologuard is also a kit that you use at home to collect stool samples. The test looks for changes in DNA in addition to checking for blood in your stool]
C2_3. Sigmoidoscopy [The doctor inserts a tube into the rectum to check only part of the colon and you are fully awake]
C2_4. Colonoscopy [The doctor inserts a tube into the rectum to check the entire colon, and you are given medication to make you sleepy, and told to have someone take you home]
C2_5. CT Colonography or Virtual Colonoscopy [Unlike regular colonoscopies, you do not need medication to make you sleepy. Your colon is filled with air and you are moved through a donut-shaped X-ray machine as you lie on your back and then your stomach]

[IF C2_1 !=1 AND C2_2!=1 AND C2_3!=1 AND C2_4!=1 AND C2_5!=1 GOTO C7, ELSE CONTINUE]

{PAGE BREAK}

C3. You indicated that you had the following test(s).

[IF C2_1 = 1] [Stool test, except Cologuard]

[IF C2_2 = 1] [Cologuard]

[IF C2_3 = 1] [Sigmoidoscopy]

[IF C2_4 = 1] [Colonoscopy]

[IF C2_5 = 1] [CT Colonography or Virtual Colonoscopy]

For each test, about how long has it been since your MOST RECENT test using the selected method?

Test	Within past year (< 12 months ago)	Within past 2 years (over 1 year but < 2 years ago)	Within past 3 years (over 2 years but < 3 years ago)	Within past 5 years (over 3 years but < 5 years ago)	Within past 10 years (over 5 years but < 10 years ago)	10+ years ago
C3_1. [IF C2_1 = 1 SHOW, ELSE SUPPRESS] Stool test, except Cologuard
C3_2. [IF C2_2 = 1 SHOW, ELSE SUPPRESS] Cologuard
C3_3. [IF C2_3 = 1 SHOW, ELSE SUPPRESS] Sigmoidoscopy
C3_4. [IF C2_4 = 1 SHOW, ELSE SUPPRESS] Colonoscopy
C3_5. [IF C2_5 = 1 SHOW, ELSE SUPPRESS] CT Colonoscopy or Virtual Colonoscopy

{PAGE BREAK}

C4. What was the reason for the following test(s)?

	Part of a routine exam / check-up	Because of a problem or symptom	Follow-up to a (positive) screening test	Other reason (e.g., family history, genetic predisposition)
C4_1. [IF C3_3 = 1,2,3,4,5 OR 6 SHOW, ELSE SUPPRESS] Sigmoidoscopy
C4_2. [IF C3_4 = 1,2,3,4,5 OR 6 SHOW, ELSE SUPPRESS] Colonoscopy
C4_3. [IF C3_5 = 1,2,3,4,5 OR 6 SHOW, ELSE SUPPRESS] CT Colonography or Virtual Colonoscopy

C4_1_OTH. [SHOW IF C4_1=4] Please specify the reason for your sigmoidoscopy test? [Optional] [OPEN FIELD]

C4_2_OTH. [SHOW IF C4_2=4] Please specify the reason for your colonoscopy test? [Optional] [OPEN FIELD]

C4_3_OTH. [SHOW IF C4_3=4] Please specify the reason for your colonography or virtual colonoscopy test? [Optional] [OPEN FIELD]

{PAGE BREAK}

C6. Before your diagnosis, were you able to schedule your colorectal cancer screening within a reasonable timeframe?

1. Yes

2. No

{PAGE BREAK}

C7. What were the top non-medical issues you faced when staying up-to-date with your colorectal cancer screening? You may select up to 5 issues. [Programmer: Only ask for colorectal cancer patients. Suppress C7, C7_RANK, and C7_FACILITATE for breast and cervical cancer patients.]

[SELECT ALL THAT APPLY – UP TO 5]
C7_1. ___	Could not afford care (e.g., cost too much; other competing expenses)
C7_2. ___	No insurance coverage, or insurance company would not approve, cover or pay for care
C7_3. ___	Problems getting transportation to/from doctor's office for cancer screening
C7_4. ___	Unable to understand the doctor’s language or language of screening instructions/materials (e.g., different language without access to interpretation)
C7_5. ___	Medical information was too hard to understand
C7_6. ___	Could not get time off work for appointments and care (e.g., no paid sick leave, no flexible work schedule, no medical leave)
C7_7. ___	Didn’t know where to go to get care (e.g., no primary doctor or usual source of care to make referral; unfamiliar with local providers; local specialty practice closed)
C7_8. ___	Was refused services (e.g., out of network provider, not accepting new patients)
C7_9. ___	Couldn’t get dependent care (e.g., for child, elderly relative, or relative with a disability)
C7_10. ___	Could not get a friend or family member to go with me to appointment
C7_11. ___	Took too long to get an appointment that worked for my schedule
C7_12. ___	Experienced discrimination (e.g., racial or ethnic discrimination, gender, weight, sexual orientation, disability status)
C7_13. ___	Afraid of the potential diagnosis, of discomfort, embarrassment, or pain associated with the screening procedure
C7_14. ___	Did not feel screening was urgent (e.g., never thought about scheduling a screening; put it off / didn’t get around to it; haven’t had any problems or symptoms)
C7_15. ___	Did not know I needed it / doctor did not say screening was needed
C7_16. ___	Other
C7_17. ___	Did not face any issues with scheduling my colorectal cancer screening. [EXCLUSIVE SELECT] [Programmer: If selected, go to C7_FACILITATE.]

{PAGE BREAK}

C7_OTH. [SHOW IF C7_16 NE BLANK] Please describe the other issue(s) that you faced when getting your colorectal cancer screening. [OPEN FIELD]

{PAGE BREAK}

C7_RANK. Of the top issues you selected, please rank them, with “1” being the most important.

[NOTE: DISPLAY ONLY THE ISSUES ENDORSED IN QUESTION C7]

[NUMERIC RESPONSE – UP TO 5]	[NUMERIC RESPONSE – UP TO 5]
C7_ RANK_1. ___	Could not afford care (e.g., cost too much; other competing expenses)
C7_ RANK_2. ___	No insurance coverage, or insurance company would not approve, cover or pay for care
C7_ RANK_3. ___	Problems getting transportation to/from doctor's office for cancer screening
C7_ RANK_4. ___	Unable to understand the doctor’s language or language of screening instructions/materials (e.g., different language without access to interpretation)
C7_ RANK_5. ___	Medical information was too hard to understand
C7_ RANK_6. ___	Could not get time off work for appointments and care (e.g., no paid sick leave, no flexible work schedule, no medical leave)
C7_ RANK_7. ___	Didn’t know where to go to get care (e.g., no primary doctor or usual source of care to make referral; unfamiliar with local providers; local specialty practice closed)
C7_ RANK_8. ___	Was refused services (e.g., out of network provider, not accepting new patients)
C7_ RANK_9. ___	Couldn’t get dependent care (e.g., for child, elderly relative, or relative with a disability)
C7_ RANK_10. ___	Could not get a friend or family member to go with me to appointment
C7_ RANK_11. ___	Took too long to get an appointment that worked for my schedule
C7_ RANK_12. ___	Experienced discrimination (e.g., racial or ethnic discrimination, gender, weight, sexual orientation, disability status)
C7_ RANK_13. ___	Afraid of the potential diagnosis, of discomfort, embarrassment, or pain associated with the screening procedure
C7_ RANK_14. ___	Did not feel screening was urgent (e.g., never thought about scheduling a screening; put it off / didn’t get around to it; haven’t had any problems or symptoms)
C7_ RANK_15. ___	Did not know I needed it / doctor did not say screening was needed
C7_ RANK_16. ___	[C7_OTH]

{PAGE BREAK}

C7_FACILITATE. Please select the top 5 factors that made it easier to get your colorectal cancer screening on-time.

[NUMERIC RESPONSE – UP TO 5]	[NUMERIC RESPONSE – UP TO 5]
C7_FACILITATE_1	Worked with a nurse/patient navigator who provided additional support
C7_FACILITATE_2	Was able to afford care
C7_FACILITATE_3	Was able to cover all my expenses like food
C7_FACILITATE_4	Had permanent, stable housing
C7_FACILITATE_5	Insurance covered most of my medical costs
C7_FACILITATE_6	Easy access to transportation
C7_FACILITATE_7	Convenient location of health care provider
C7_FACILITATE_8	Was able to take time off work for appointment (e.g., paid sick leave, flexible work schedule, medical leave available)
C7_FACILITATE_9	Connected to a provider by someone I know (e.g., doctor, nurse, family member, friend, others on social media)
C7_FACILITATE_10	Was able to get an appointment with a doctor or specialist within a reasonable timeframe
C7_FACILITATE_11	Was able to make arrangements for dependent care (e.g., for child, elderly relative, or relative with a disability), if needed
C7_FACILITATE_12	Was treated with respect by my doctor or specialist
C7_FACILITATE_13	Was able to understand medical information that was shared with me
C7_FACILITATE_14	Other [please specify]: ___OPEN TEXT FIELD

{PAGE BREAK}

MODULE D: CERVICAL

[IF A2=2 CONTINUE, ELSE GO TO E1]

D1. The next questions are about cervical cancer screening tests.

{PAGE BREAK}

D2. There are two different kinds of tests to check for cervical cancer. One is a Pap smear or Pap test and the other is the HPV or Human Papillomavirus test. Have you ever had a test to check for cervical cancer? These are tests for women in which a doctor or other health professional takes a sample from the cervix with a swab or brush and sends it to the lab.	Yes	No	Don’t know
D2_1. Pap smear or Pap test
D2_2. HPV or Human Papillomavirus test

[IF D2_1 !=1 AND D2_2!=1 GOTO D7, ELSE CONTINUE]

{PAGE BREAK}

D3. You indicated that you had the following test(s).

[IF D2_1 = 1] [Pap smear or Pap test]

[IF D2_2 = 1] [HPV or Human Papillomavirus test]

For each test, about how long has it been since your MOST RECENT test using the selected method?

Test	Within past year (< 12 months ago)	Within past 2 years (over 1 year but < 2 years ago)	Within past 3 years (over 2 years but < 3 years ago)	Within past 5 years (over 3 years but < 5 years ago)	Within past 10 years (over 5 years but < 10 years ago)	10+ years ago
D3_1. [IF D2_1 = 1 SHOW, ELSE SUPPRESS] Pap smear or Pap test
D3_2. [IF D2_2 = 1 SHOW, ELSE SUPPRESS] HPV or Human Papillomavirus test

{PAGE BREAK}

D4. What was the reason for each test?

	Part of a routine exam / check-up	Because of a problem or symptom	Follow-up to a (positive) screening test	Other reason (e.g., family history, genetic predisposition)
D4_1. [IF D3_1 = 1,2,3,4,5 OR 6 SHOW, ELSE SUPPRESS] Pap smear or Pap test
D4_2. [IF D3_2 = 1,2,3,4,5 OR 6 SHOW, ELSE SUPPRESS] HPV or Human Papillomavirus test

D4_1_OTH. [SHOW IF D4_1=4] Please specify the reason for your Pap smear or Pap test? [Optional] [OPEN FIELD]

D4_2_OTH. [SHOW IF D4_2=4] Please specify the reason for your HPV or Human Papillomavirus test? [Optional] [OPEN FIELD]

{PAGE BREAK}

D6. Before your diagnosis, were you able to schedule your cervical cancer screening within a reasonable timeframe?

1. Yes

2. No

88. Don’t know

{PAGE BREAK}

D7. What were the top non-medical issues you faced when staying up-to-date with your cervical cancer screening? You may select up to 5 issues. [Programmer: Only ask for cervical cancer patients. Suppress D7, D7_RANK, and D7_FACILITATE for colorectal and breast cancer patients.]

[SELECT ALL THAT APPLY – UP TO 5]
D7_1. ___	Could not afford care (e.g., cost too much; other competing expenses)
D7_2. ___	No insurance coverage, or insurance company would not approve, cover or pay for care
D7_3. ___	Problems getting transportation to/from doctor's office for cancer screening
D7_4. ___	Unable to understand the doctor’s language or language of screening instructions/materials (e.g., different language without access to interpretation)
D7_5. ___	Medical information was too hard to understand
D7_6. ___	Could not get time off work for appointments and care (e.g., no paid sick leave, no flexible work schedule, no medical leave)
D7_7. ___	Didn’t know where to go to get care (e.g., no primary doctor or usual source of care to make referral; unfamiliar with local providers; local specialty practice closed)
D7_8. ___	Was refused services (e.g., out of network provider, not accepting new patients)
D7_9. ___	Couldn’t get dependent care (e.g., for child, elderly relative, or relative with a disability)
D7_10. ___	Could not get a friend or family member to go with me to appointment
D7_11. ___	Took too long to get an appointment that worked for my schedule
D7_12. ___	Experienced discrimination (e.g., racial or ethnic discrimination, gender, weight, sexual orientation, disability status)
D7_13. ___	Afraid of the potential diagnosis, of discomfort, embarrassment, or pain associated with the screening procedure
D7_14. ___	Did not feel screening was urgent (e.g., never thought about scheduling a screening; put it off / didn’t get around to it; haven’t had any problems or symptoms)
D7_15. ___	Did not know I needed it / doctor did not say screening was needed
D7_16. ___	Had HPV vaccines and did not think screening was needed
D7_17. ___	Other
D7_18. ___	Did not face any issues with scheduling my cervical cancer screening. [EXCLUSIVE SELECT] [Programmer: If selected, go to D7_FACILITATE.]

{PAGE BREAK}

D7_OTH. [SHOW IF D7_17 NE BLANK] Please describe the other issue(s) that you faced when scheduling your cervical cancer screening. [OPEN FIELD]

{PAGE BREAK}

D7_RANK. Of the top issues you selected, please rank them , with “1” being the most important.

[NOTE: DISPLAY ONLY THE ISSUES ENDORSED IN QUESTION D7]

[NUMERIC RESPONSE – UP TO 5]	[NUMERIC RESPONSE – UP TO 5]
D7_ RANK_1. ___	Could not afford care (e.g., cost too much; other competing expenses)
D7_ RANK_2. ___	No insurance coverage, or insurance company would not approve, cover or pay for care
D7_ RANK_3. ___	Problems getting transportation to/from doctor's office for cancer screening
D7_ RANK_4. ___	Unable to understand the doctor’s language or language of screening instructions/materials (e.g., different language without access to interpretation)
D7_ RANK_5. ___	Medical information was too hard to understand
D7_ RANK_6. ___	Could not get time off work for appointments and care (e.g., no paid sick leave, no flexible work schedule, no medical leave)
D7_ RANK_7. ___	Didn’t know where to go to get care (e.g., no primary doctor or usual source of care to make referral; unfamiliar with local providers; local specialty practice closed)
D7_ RANK_8. ___	Was refused services (e.g., out of network provider, not accepting new patients)
D7_ RANK_9. ___	Couldn’t get dependent care (e.g., for child, elderly relative, or relative with a disability)
D7_ RANK_10. ___	Could not get a friend or family member to go with me to appointment
D7_ RANK_11. ___	Took too long to get an appointment that worked for my schedule
D7_ RANK_12. ___	Experienced discrimination (e.g., racial or ethnic discrimination, gender, weight, sexual orientation, disability status)
D7_ RANK_13. ___	Afraid of the potential diagnosis, of discomfort, embarrassment, or pain associated with the screening procedure
D7_ RANK_14. ___	Did not feel screening was urgent (e.g., never thought about scheduling a screening; put it off / didn’t get around to it; haven’t had any problems or symptoms)
D7_ RANK_15. ___	Did not know I needed it / doctor did not say screening was needed
D7_ RANK_16. ___	Had HPV vaccines and did not think screening was needed
D7_ RANK_17. ___	[D7_OTH]

{PAGE BREAK}

D7_FACILITATE. Please select the top 5 factors that made it easier to get your cervical cancer screening on-time.

[NUMERIC RESPONSE – UP TO 5]	[NUMERIC RESPONSE – UP TO 5]
D7_FACILITATE_1	Worked with a nurse/patient navigator who provided additional support
D7_FACILITATE_2	Was able to afford care
D7_FACILITATE_3	Was able to cover all my expenses like food
D7_FACILITATE_4	Had permanent, stable housing
D7_FACILITATE_5	Insurance covered most of my medical costs
D7_FACILITATE_6	Easy access to transportation
D7_FACILITATE_7	Convenient location of health care provider
D7_FACILITATE_8	Was able to take time off work for appointment (e.g., paid sick leave, flexible work schedule, medical leave available)
D7_FACILITATE_9	Connected to a provider by someone I know (e.g., doctor, nurse, family member, friend, others on social media)
D7_FACILITATE_10	Was able to get an appointment with a doctor or specialist within a reasonable timeframe
D7_FACILITATE_11	Was able to make arrangements for dependent care (e.g., for child, elderly relative, or relative with a disability), if needed
D7_FACILITATE_12	Was treated with respect by my doctor or specialist
D7_FACILITATE_13	Was able to understand medical information that was shared with me
D7_FACILITATE_14	Other [please specify]: ___OPEN TEXT FIELD

{PAGE BREAK}

MODULE E: BREAST

[IF A2=2 OR A3=5,6,7,8,9,10,11, OR 12 CONTINUE, ELSE GOTO F1]

E1. The next questions are about breast cancer screening tests, or mammograms.

A mammogram is an x-ray taken only of the breast by a machine that presses against the breast.

Have you ever had a mammogram to check for breast cancer?

1. Yes

2. No

[IF E1 !=1 GOTO E6, ELSE CONTINUE]

{PAGE BREAK}

E2. You indicated that you had a mammogram. About how long has it been since your MOST RECENT mammogram?

1. Within past year (Less than 12 months ago)

2. Within past 2 years (over 1 year but less than 2 years ago)

3. Within past 3 years (over 2 years but less than 3 years ago)

4. Within past 5 years (over 3 years but less than 5 years ago)

5. Within past 10 years (over 5 years but less than 10 years ago)

6. 10 or more years ago

88. Don’t know

[IF E2 =88 OR 99 GOTO E6, ELSE CONTINUE]

{PAGE BREAK}

E3. What was the reason for your mammogram?

1. Part of a routine exam / check-up

2. Because of a problem or symptom

3. Follow-up to a (positive) screening test

4. Other reason (e.g., family history, genetic predisposition)

E3_OTH. [SHOW IF E3=4] Please specify the reason for your mammogram? [Optional] [OPEN FIELD]

{PAGE BREAK}

E5. Before your diagnosis, were you able to schedule your mammogram within a reasonable timeframe?

1. Yes

2. No

{PAGE BREAK}

E6. What were the top non-medical issues you faced when staying up-to-date with your mammogram? You may select up to 5 issues. [Programmer: Only ask for breast cancer patients. Suppress E6, E6_RANK, and E6_FACILITATE for colorectal and cervical cancer patients.]

[SELECT ALL THAT APPLY – UP TO 5]
E6_1. ___	Could not afford care (e.g., cost too much; other competing expenses)
E6_2. ___	No insurance coverage, or insurance company would not approve, cover or pay for care
E6_3. ___	Problems getting transportation to/from doctor's office for cancer screening
E6_4. ___	Unable to understand the doctor’s language (e.g., different language without access to interpretation)
E6_5. ___	Medical information was too hard to understand
E6_6. ___	Could not get time off work for appointments and care (e.g., no paid sick leave, no flexible work schedule, no medical leave)
E6_7. ___	Didn’t know where to go to get care (e.g., no primary doctor or usual source of care to make referral; unfamiliar with local providers; local specialty practice closed)
E6_8. ___	Was refused services (e.g., out of network provider, not accepting new patients)
E6_9. ___	Couldn’t get dependent care (e.g., for child, elderly relative, or relative with a disability)
E6_10. ___	Could not get a friend or family member to go with me to appointment
E6_11. ___	Took too long to get an appointment that worked for my schedule
E6_12. ___	Experienced discrimination (e.g., racial or ethnic discrimination, gender, weight, sexual orientation, disability status)
E6_13. ___	Afraid of the potential diagnosis, of discomfort, embarrassment, or pain associated with the screening procedure
E6_14. ___	Did not feel screening was urgent (e.g., never thought about scheduling a screening; put it off / didn’t get around to it; haven’t had any problems or symptoms)
E6_15. ___	Did not know I needed it / doctor did not say screening was needed
E6_16. ___	Other
E6_17. ___	Did not face any issues with scheduling my mammogram. [EXCLUSIVE SELECT] [Programmer: If selected, go to E6_FACILITATE.]

{PAGE BREAK}

E6_OTH. [SHOW IF E6_16 NE BLANK] Please describe the other issue(s) that you faced when staying up to date with your mammogram. [OPEN FIELD]

{PAGE BREAK}

E6_RANK. Of the top issues you selected, please rank them , with “1” being the most important.

[NOTE: DISPLAY ONLY THE ISSUES ENDORSED IN QUESTION E6]

[NUMERIC RESPONSE – UP TO 5]	[NUMERIC RESPONSE – UP TO 5]
E6_RANK_1. ___	Could not afford care (e.g., cost too much; other competing expenses)
E6_ RANK_2. ___	No insurance coverage, or insurance company would not approve, cover or pay for care
E6_ RANK_3. ___	Problems getting transportation to/from doctor's office for cancer screening
E6_ RANK_4. ___	Unable to understand the doctor’s language (e.g., different language without access to interpretation)
E6_ RANK_5. ___	Medical information was too hard to understand
E6_ RANK_6. ___	Could not get time off work for appointments and care (e.g., no paid sick leave, no flexible work schedule, no medical leave)
E6_ RANK_7. ___	Didn’t know where to go to get care (e.g., no primary doctor or usual source of care to make referral; unfamiliar with local providers; local specialty practice closed)
E6_ RANK_8. ___	Was refused services (e.g., out of network provider, not accepting new patients)
E6_ RANK_9. ___	Couldn’t get dependent care (e.g., for child, elderly relative, or relative with a disability)
E6_ RANK_10. ___	Could not get a friend or family member to go with me to appointment
E6_ RANK_11. ___	Took too long to get an appointment that worked for my schedule
E6_ RANK_12. ___	Experienced discrimination (e.g., racial or ethnic discrimination, gender, weight, sexual orientation, disability status)
E6_ RANK_13. ___	Afraid of the potential diagnosis, of discomfort, embarrassment, or pain associated with the screening procedure
E6_ RANK_14. ___	Did not feel screening was urgent (e.g., never thought about scheduling a screening; put it off / didn’t get around to it; haven’t had any problems or symptoms)
E6_ RANK_15. ___	Did not know I needed it / doctor did not say screening was needed
E6_ RANK_16. ___	[E6_OTH]

{PAGE BREAK}

E6_FACILITATE. Please select the top 5 factors that made it easier to get your mammogram on-time.

[NUMERIC RESPONSE – UP TO 5]	[NUMERIC RESPONSE – UP TO 5]
E6_FACILITATE_1	Worked with a nurse/patient navigator who provided additional support
E6_FACILITATE_2	Was able to afford care
E6_FACILITATE_3	Was able to cover all my expenses like food
E6_FACILITATE_4	Had permanent, stable housing
E6_FACILITATE_5	Insurance covered most of my medical costs
E6_FACILITATE_6	Easy access to transportation
E6_FACILITATE_7	Convenient location of health care provider
E6_FACILITATE_8	Was able to take time off work for appointment (e.g., paid sick leave, flexible work schedule, medical leave available)
E6_FACILITATE_9	Connected to a provider by someone I know (e.g., doctor, nurse, family member, friend, others on social media)
E6_FACILITATE_10	Was able to get an appointment with a doctor or specialist within a reasonable timeframe
E6_FACILITATE_11	Was able to make arrangements for dependent care (e.g., for child, elderly relative, or relative with a disability), if needed
E6_FACILITATE_12	Was treated with respect by my doctor or specialist
E6_FACILITATE_13	Was able to understand medical information that was shared with me
E6_FACILITATE_14	Other [please specify]: ___OPEN TEXT FIELD

{PAGE BREAK}

MODULE F: DIAGNOSIS

The next few questions are about the process of getting your cancer diagnosis.

F1. Did you receive an initial misdiagnosis prior to your cancer diagnosis?

1. Yes

2. No

{PAGE BREAK}

F2. How much time passed between your first test (e.g., positive screening test or test that you had because of symptoms) and receiving your cancer diagnosis? 

 

1. Less than 1 month

2. 1 month to under 2 months 

3. 2 months to under 3 months

4. 3 months to under 6 months

5. 6 months or more

88. Don’t Know

{PAGE BREAK}

F3. What were the top non-medical issues you faced when getting your cancer diagnosis?

You may select up to 5 issues.

[SELECT ALL THAT APPLY – UP TO 5]
F3_1. ___	Could not afford care (e.g., cost too much; other competing expenses)
F3_2. ___	No insurance coverage, or insurance company would not approve, cover, or pay for care
F3_3. ___	Problems getting transportation to/from doctor's office to undergo a procedure
F3_4. ___	Unable to understand the doctor’s language (e.g., different language without access to interpretation)
F3_5. ___	Medical information was too hard to understand
F3_6. ___	Could not get time off work for appointments and care (e.g., no paid sick leave, no flexible work schedule)
F3_7. ___	Didn’t know where to go to get care (e.g., no primary doctor or usual source of care to make referral; unfamiliar with local providers; local specialty practice closed)
F3_8. ___	Was refused services (e.g., out of network provider, not accepting new patients)
F3_9. ___	Couldn’t get dependent care (e.g., for child, elderly relative, or relative with a disability)
F3_10. ___	Could not get a friend or family member to go with me to appointment
F3_11. ___	Took too long to get an appointment that worked for my schedule
F3_12. ___	Experienced discrimination (e.g., racial or ethnic, gender, weight, sexual orientation, disability status discrimination)
F3_13. ___	Afraid of the potential diagnosis, or of hearing diagnosis without a loved one present
F3_14. ___	Other
F3_15. ___	Did not encounter any issues. [EXCLUSIVE SELECT] [Programmer: If selected, go to F3_FACILITATE.]

{PAGE BREAK}

F3_OTH. [SHOW IF F3_14 NE BLANK] Please describe the other issue(s) that you faced when getting your cancer diagnosis. [OPEN FIELD]

{PAGE BREAK}

F3_RANK. Of the issues you selected, please rank them , with “1” being the most important.

[NOTE: DISPLAY ONLY THE ISSUES ENDORSED IN QUESTION F3]

[NUMERIC RESPONSE – UP TO 5]	[NUMERIC RESPONSE – UP TO 5]
F3_RANK_1. ___	Could not afford care (e.g., cost too much; other competing expenses)
F3_ RANK_2. ___	No insurance coverage, or insurance company would not approve, cover, or pay for care
F3_ RANK_3. ___	Problems getting transportation to/from doctor’s office to undergo a procedure
F3_ RANK_4. ___	Unable to understand the doctor’s language (e.g., different language without access to interpretation)
F3_ RANK_5. ___	Medical information was too hard to understand
F3_ RANK_6. ___	Could not get time off work for appointments and care (e.g., no paid sick leave, no flexible work schedule)
F3_ RANK_7. ___	Didn’t know where to go to get care (e.g., no primary doctor or usual source of care to make referral; unfamiliar with local providers; local specialty practice closed)
F3_ RANK_8. ___	Was refused services (e.g., out of network provider, not accepting new patients)
F3_ RANK_9. ___	Couldn’t get dependent care (e.g., for child, elderly relative, or relative with a disability)
F3_ RANK_10. ___	Could not get a friend or family member to go with me to appointment
F3_ RANK_11. ___	Took too long to get an appointment that worked for my schedule
F3_ RANK_12. ___	Experienced discrimination (e.g., racial or ethnic, gender, weight, sexual orientation, disability status discrimination)
F3_ RANK_13. ___	Afraid of the potential diagnosis, or of hearing diagnosis without a loved one present
F3_ RANK_14. ___	[F3_OTH]

{PAGE BREAK}

F3_FACILITATE. Please select the top 5 factors that made it easier for you to get a timely cancer diagnosis.

[NUMERIC RESPONSE – UP TO 5]	[NUMERIC RESPONSE – UP TO 5]
F3_FACILITATE_1	Worked with a nurse/patient navigator who provided additional support
F3_FACILITATE_2	Was able to afford care
F3_FACILITATE_3	Was able to cover all my expenses like food
F3_FACILITATE_4	Had permanent, stable housing
F3_FACILITATE_5	Insurance covered most of my medical costs
F3_FACILITATE_6	Easy access to transportation
F3_FACILITATE_7	Convenient location of health care provider
F3_FACILITATE_8	Was able to take time off work for appointment (e.g., paid sick leave, flexible work schedule, medical leave available)
F3_FACILITATE_9	Connected to a provider by someone I know (e.g., doctor, nurse, family member, friend, others on social media)
F3_FACILITATE_10	Was able to get an appointment with a doctor or specialist within a reasonable timeframe
F3_FACILITATE_11	Was able to make arrangements for dependent care (e.g., for child, elderly relative, or relative with a disability), if needed
F3_FACILITATE_12	Was treated with respect by my doctor or specialist
F3_FACILITATE_13	Was able to understand medical information that was shared with me
F3_FACILITATE_14	Other [please specify]: ___OPEN TEXT FIELD

{PAGE BREAK}

F4. Did you seek a second opinion about your cancer diagnosis?

1. Yes à Go to F4a

2. No

F4a. Were you able to receive the second opinion in a reasonable timeframe (e.g., within 3 weeks)?

1. Yes

2. No

88. Don’t know

{PAGE BREAK}

F5. How difficult was it to see a doctor about your cancer diagnosis?

1. Not at all difficult

2. Slightly difficult

3. Difficult

4. Very difficult

{PAGE BREAK}

MODULE G: TREATMENT

G1. The next questions are about your cancer treatment.

Were you able to begin treatment on-schedule with your doctor’s recommendation?

1. Yes

2. No, the start of my treatment was delayed (e.g., I chose to delay, or my provider was unavailable)

3. No, I chose not to engage in medical treatment.

G1_SPEC1. [SHOW IF G1=2] Please specify why the start of treatment was delayed (Optional): [OPEN FIELD]

G1_SPEC2. [SHOW IF G1=3] Please specify what, if anything, you are or were doing as an alternative to medical treatment (Optional): [OPEN FIELD]

{PAGE BREAK}

G2. What were the top non-medical issues you faced during your cancer treatment?

You may select up to 5 issues.

[SELECT ALL THAT APPLY – UP TO 5]
G2_1. ___	Could not afford care (e.g., cost too much; other competing expenses)
G2_2. ___	No insurance coverage, or insurance company would not approve, cover, or pay for care
G2_3. ___	Problems getting transportation to/from doctor's office for treatment
G2_4. ___	Unable to understand the doctor’s language (e.g., different language without access to interpretation)
G2_5. ___	Medical information was too hard to understand
G2_6. ___	Could not get time off work for appointments and care (e.g., no paid sick leave, no flexible work schedule, no medical leave)
G2_7. ___	Didn’t know where to go to get care (e.g., no primary doctor or usual source of care to make referral; unfamiliar with local providers; local specialty practice closed)
G2_8. ___	Was refused services (e.g., out of network provider, not accepting new patients)
G2_9. ___	Couldn’t get dependent care (e.g., for child, elderly relative, or relative with a disability)
G2_10. ___	Could not get a friend or family member to go with me to appointment
G2_11. ___	Took too long to get an appointment that worked for my schedule
G2_12. ___	Experienced discrimination (e.g., racial or ethnic, gender, weight, sexual orientation, disability status discrimination)
G2_13. ___	Afraid the treatment will be too painful or unpleasant
G2_14. ___	Other
G2_15. ___	Did not encounter any issues. [EXCLUSIVE SELECT] [Programmer: If selected, go to G2_FACILITATE.]

{PAGE BREAK}

G2_OTH. [SHOW IF G2_14 NE BLANK] Please describe the other issue(s) that you faced during your cancer treatment. [OPEN FIELD]

{PAGE BREAK}

G2_RANK. Of the top issues you selected, please rank them , with “1” being the most important.

[NOTE: DISPLAY ONLY THE ISSUES ENDORSED IN QUESTION G2]

[NUMERIC RESPONSE – UP TO 5]	[NUMERIC RESPONSE – UP TO 5]
G2_ RANK_1. ___	Could not afford care (e.g., cost too much; other competing expenses)
G2_ RANK_2. ___	No insurance coverage, or insurance company would not approve, cover, or pay for care
G2_ RANK_3. ___	Problems getting transportation to/from doctor's office for treatment
G2_ RANK_4. ___	Unable to understand the doctor’s language (e.g., different language without access to interpretation)
G2_ RANK_5. ___	Medical information was too hard to understand
G2_ RANK_6. ___	Could not get time off work for appointments and care (e.g., no paid sick leave, no flexible work schedule, no medical leave)
G2_ RANK_7. ___	Didn’t know where to go to get care (e.g., no primary doctor or usual source of care to make referral; unfamiliar with local providers; local specialty practice closed)
G2_ RANK_8. ___	Was refused services (e.g., out of network provider, not accepting new patients)
G2_ RANK_9. ___	Couldn’t get dependent care (e.g., for child, elderly relative, or relative with a disability)
G2_ RANK_10. ___	Could not get a friend or family member to go with me to appointment
G2_ RANK_11. ___	Took too long to get an appointment that worked for my schedule
G2_ RANK_12. ___	Experienced discrimination (e.g., racial or ethnic, gender, weight, sexual orientation, disability status discrimination)
G2_ RANK_13. ___	Afraid the treatment will be too painful or unpleasant
G2_ RANK_14. ___	[G2_OTH]

{PAGE BREAK}

G2_FACILITATE. Please select the top 5 factors that made it easier to get medical care for your cancer treatment.

[NUMERIC RESPONSE – UP TO 5]	[NUMERIC RESPONSE – UP TO 5]
G2_FACILITATE_1	Worked with a nurse/patient navigator who provided additional support
G2_FACILITATE_2	Was able to manage side effects
G2_FACILITATE_3	Was able to afford care
G2_FACILITATE_4	Was able to cover all my expenses like food
G2_FACILITATE_5	Had permanent, stable housing
G2_FACILITATE_6	Insurance covered most of my medical costs
G2_FACILITATE_7	Easy access to transportation
G2_FACILITATE_8	Convenient location of health care provider
G2_FACILITATE_9	Was able to take time off work for appointments and care (e.g., paid sick leave, flexible work schedule, medical leave available)
G2_FACILITATE_10	Connected to a provider by someone I know (e.g., doctor, nurse, family member, friend, others on social media)
G2_FACILITATE_11	Was able to get an appointment with a doctor or specialist within a reasonable timeframe
G2_FACILITATE_12	Was able to make arrangements for dependent care (e.g., for child, elderly relative, or relative with a disability), if needed
G2_FACILITATE_13	Was treated with respect by my doctor or specialist
G2_FACILITATE_14	Was able to understand medical information that was shared with me
G2_FACILITATE_15	Other [please specify]: ___OPEN TEXT FIELD

{PAGE BREAK}

G3. Have you experienced any of the following challenges in accessing cancer care or treatment due to the COVID-19 pandemic? Please select all that apply.

1. I had a hard time getting an appointment because of limited appointments or clinic availability.

2. I didn’t go to an appointment because it was only available by telephone or video call.

3. I didn’t go to an appointment because I was worried about exposure to COVID-19.

4. I didn’t go to an appointment because I tested positive for COVID-19.

5. I couldn’t get to an appointment because my caregiver was not able to come with me (e.g., due to contact restrictions, not wanting to be exposed to COVID-19, or caregiver was an essential worker and unable to take time off work).

6. My appointment was postponed.

7. My appointment was cancelled.

8. I had challenges getting my cancer prescriptions filled.

9. Other challenges – Please specify: [SHOW OPEN FIELD IF SELECTED]

10. I have not experienced any challenges in getting timely cancer care and treatment. [EXCLUSIVE]

{PAGE BREAK}

G4. What precautions did your provider take while you received treatment during the pandemic? Select all that apply.

1. Required masks

2. Added hand sanitizer to waiting room and/or exam rooms

3. Put social distancing measures in place in waiting room

4. Limited number of family members who could accompany me to appointments

5. Closed the waiting room (patients check in by phone)

6. Limited number of patients in the office at the same time/reduced number of daily appointments

7. Required COVID screening (e.g., temperature check, symptom screener) prior to entering building for treatment

8. Added air purifiers to treatment room(s)

9. Extended access to clinical staff (e.g., 24/7 nurses’ line, weekend office hours) to prevent emergency department visits due to side effects

10. Required all clinic staff to be up-to-date with COVID vaccination

11. Offered telehealth visits

12. Other – Please specify: [SHOW IF SELECTED – OPEN]

88. Don’t know [EXCLUSIVE]

{PAGE BREAK}

G5. Were there any precautionary measures for COVID-19 that were a barrier to you receiving treatment? [PROGRAMMER: SKIP if G4_88=1]

1. Yes

2. No

G5._SPEC [SHOW if G5=1 ] Please describe your experience (optional): [OPEN FIELD]

{PAGE BREAK}

G6. Below is a list of statements that other people with your illness have said are important. Please select your response to the following statement as it applies to the past 7 days.	1 – Not at all	2 – A little bit	3 – Some-what	4 – Quite a bit	5 – Very much
G6_1. I have a lack of energy.
G6_2. I have pain.
G6_3. I have nausea.
G6_4. I worry that my condition will get worse.
G6_5. I am sleeping well.
G6_6. I am able to enjoy life.
G6_7. I am content with the quality of my life right now.

{PAGE BREAK}

G7. What types of cancer treatment have you received? If you have been diagnosed with cancer more than once, please think about treatment for your most recent diagnosis for [CANC_TYPE] cancer. Select all that apply.

1. IV Chemotherapy

2. Oral Chemotherapy

3. Radiation

4. Surgery

5. Immunotherapy (e.g., interferon or cancer vaccines) or another biological therapy (e.g., Car-T, Gleevec, Iressa, Tarceva, Herceptin, or Erbitux)

6. Hormonal therapy (e.g., Tamoxifen, Adjuvant, Zoladex, Lupron)

7. Precision medicine / targeted therapy (using medication to target specific genes and proteins of the cancer)

8. Bone marrow or stem cell transplant

9. Complementary and alternative therapy (e.g., acupuncture, reiki)

10. Other – Please specify: [SHOW OPEN FIELD IF SELECTED]

11. I have not received any medical treatment for cancer [EXCLUSIVE]

{PAGE BREAK}

G8. Please select whether you have completed the following treatment(s) for your [CANC_TYPE] cancer. [Programmer: For all treatment modalities selected in G7, add a column of yes/no responses, indicating they have completed or not completed treatment.

Do not show this question to any who answered G7_11]

	Completed treatment?
	Yes	No	Don’t know
IV Chemotherapy	o	o	o
Oral Chemotherapy	o	o	o
Radiation	o	o	o
Surgery	o	o	o
Immunotherapy (e.g., interferon or cancer vaccines) or another biological therapy (e.g., Car-T, Gleevec, Iressa, Tarceva, Herceptin, or Erbitux)	o	o	o
Hormonal therapy (e.g., Tamoxifen, Adjuvant, Zoladex, Lupron)	o	o	o
Precision medicine / targeted therapy (using medication to target specific genes and proteins of the cancer)	o	o	o
Bone marrow or stem cell transplant	o	o	o
Complementary and alternative therapy (e.g., acupuncture, reiki)	o	o	o
Other – Please specify: [SHOW OPEN FIELD IF SELECTED]	o	o	o

{PAGE BREAK}

G9. When choosing a treatment course for your cancer, did you consider the costs of specific treatments?

1. Yes, a great deal

2. Yes, somewhat

3. No, not at all

{PAGE BREAK}

G10. How would you describe your reaction to the money you spent or you are spending for cancer treatment?

I spent/am spending…

1. …more money than I expected

2. …about as much money as I expected

3. …less money than I expected

{PAGE BREAK}

G11. Overall, how informed did you feel about the potential side effects from treatment?

1. Very

2. Somewhat

3. Not at all

G11._OPEN [SHOW if G11=1 OR 2 OR 3] Please describe your experience (optional): [OPEN FIELD]

{PAGE BREAK}

G12. In general, how often did your doctor(s) or other healthcare providers show respect for what you had to say?

1. Never

2. Sometimes

3. Usually

4. Always

G12._OPEN [SHOW if G12=1 OR 2 OR 3 OR 4] Please describe your experience (optional): [OPEN FIELD]

{PAGE BREAK}

G13. In general, how often did your doctor(s) or other healthcare providers give you as much cancer-related information as you wanted?

1. Never

2. Sometimes

3. Usually

4. Always

G13._OPEN [SHOW if G13=1 OR 2 OR 3 OR 4] Please describe your experience (optional): [OPEN FIELD]

{PAGE BREAK}

MODULE H: CONTACT

{PAGE BREAK} 

 

H1a. We will be conducting 1-hour phone /online interviews with a subset of individuals diagnosed with or living with cancer who complete this survey and are willing to volunteer their time.  The purpose of the interview is to learn more about your experiences from cancer screening through treatment and beyond. Would you like to be considered to participate in a 1-hour phone/online interview? 

1. Yes  

2. No 

 

{PAGE BREAK} 

H1b.  [SHOW IF H1a=1] Please provide your phone number: [OPEN] 

H1c. [SHOW IF H1a=1] Please provide your e-mail address: [OPEN] 

H1d. Please retype the email address for confirmation: [OPEN]  

 

EMAIL_CHK2.  [IF H1c != H1d: The email address that you provided does not match. Please click [Next] to make any corrections.]  

 

{PAGE BREAK}  

H1e. The support of a caregiver during your cancer journey can be important. A person in this role typically provides ongoing support at multiple times during your cancer treatment.

If you had someone who fits this description, may we contact them about participating in a brief survey? The survey will ask about their experience providing care. Caregivers must be 18 years of age or older to participate in the survey. They will receive $40 for completing the survey.

1. Yes

2. No

{PAGE BREAK}

H2. Please provide the name, address, and email-address for this caregiver.

H2_1. Name: [OPEN]

H2_2. Street address line 1: [OPEN]

H2_3. Street address line 2: [OPEN]

H2_4. City [OPEN]

H2_5: State: [OPEN]

H2_6: Zip code [OPEN – ALLOW 5-DIGIT ZIP CODE]

H3: E-mail address: [OPEN]

H4: Please retype the email address for confirmation: [OPEN]

[IF H3 != H4: The email address that you provided does not match. Please click [Next] to make any corrections.]

{PAGE BREAK}

H5_INCENT. As a thank you for completing this survey, we will provide you with $40. Do you prefer to receive an electronic VISA gift card emailed to you or a check mailed to your home?

Processing time for an e-card is about a week. Processing time for a check is about 3-4 weeks.

1. Electronic gift card emailed to me

2. Check mailed to my home

{PAGE BREAK}

H6. [IF H5_INCENT = 2] Please enter your contact information so that we may send you a $40 check.

H6_1. Name: [OPEN]

H6_2. Street address line 1: [OPEN]

H6_3. Street address line 2: [OPEN]

H6_4. City [OPEN]

H6_5: State: [OPEN]

H6_6: Zip code [OPEN – ALLOW 5-DIGIT ZIP CODE]

[POST LOGIC: GO TO END]

{PAGE BREAK}

H6: [IF H5_INCENT=1] Please enter your e-mail address for the $40 electronic gift card: [OPEN]

H7: Please retype the email address for confirmation: [OPEN]

[IF H6 != H7: The email address that you provided does not match. Please click [Next] to make any corrections.]

{PAGE BREAK}

END.

Thank you!

If you have any questions about the survey, please do not hesitate to call us toll free at (833) 997-2714 or email us at [email protected]. We may contact you again to complete another brief follow-up survey. Please click [SUBMIT] to submit your responses.

[END SURVEY– REDIRECT TO COMPLETE]

{PAGE BREAK}

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-####).