Cx3 Study - Baseline Patient Survey

CDC Cervical Cancer Study (CX3)

Att E1_HPV Baseline Patient Survey_0209

Cx3 Study - Baseline Patient Survey

OMB: 0920-0814

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0814 can be found here:

2012-05-22 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

STUDY
LOGO
HERE

Cervical Cancer Study
Patient Survey–Baseline

Form Approved
OMB Control No. 0920-xxxx
Expiration Date: xx/xx/20xx

The Centers for Disease Control and Prevention (CDC) is doing a survey to understand
women’s views and experiences about cervical cancer screening. Answering these questions
will help CDC create new materials to help women protect themselves from cervical cancer.
¾ The survey should take about 20 minutes to complete.
¾ Your name is not included on your survey.
¾ Your answers will be kept private to the extent allowed by law.
¾ Answers from approximately 2,600 women will be combined.
¾ Some of the questions are personal but provide important information for this
study.
¾ It is your choice to complete the survey. You may choose to skip any questions
that you do not want to answer.
¾ Only people connected with this survey will see your answers. Your doctor will
not see them.
¾ Your doctor will give you the same care, whether you choose to take the survey
or not.
We thank you very much for taking your time to take this survey for us.

When you are done, please put the survey into the
attached envelope, and return it to the Study Coordinator.

Thank you!

Centers for Public Health Research and Evaluation
1100 Dexter Avenue N., Suite 400
Seattle, Washington 98109-3598

Public reporting burden of this collection of information varies from 18 to 23 minutes with an estimated average of 20 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining 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 D74, Atlanta, Georgia 30333; ATTN: PRA (xxxx-xxxx)

Cervical Cancer Study: Patient Survey

Page 1

PART A: Information About You
This part of the survey asks questions that will help us describe the survey participants.
Please write in or check (9) the best answer.

A1.

What is your date of birth?

MONTH

A2.

A3.

Are you of Hispanic or Latina origin?

Yes
No

What is your race or racial heritage?

White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native

Never married
Unmarried, living with partner
Married
Separated/Divorced
Widowed

Please 9 all that apply.

A4.

What is your marital status?

Please 9 only one.

A5.

A6.

YEAR

What is the highest level of schooling you have
finished? Please 9 only one.

Which type of health insurance do you have?

Please 9 all that apply.

Elementary school (preschool to 6th grade)
Middle School (7th or 8th grade)
High School (9th – 12th grade – No Diploma)
High School Diploma or GED
Some college credit or associate degree (AA)
College bachelor’s degree (BS, BA, AB)
College masters or doctoral degree (MS, MA,
MSW, PhD, MD)

Private insurance (Kaiser, Blue Cross, Aetna,
etc.)
Medicare (including Medicare managed care)
Medicaid / Medical Coupons
Military or Veterans Administration
Illinois Breast and Cervical Cancer Program
(BCCP)
No insurance (Self-pay for all health care
costs)
Other. Please specify: __________________

_______________________________________
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Cervical Cancer Study: Patient Survey

A7.

In what country were you born?

Page 2

USA
Other. Please specify the name of the country:

_______________________________________
A8.

A9.

If you were not born in the United States, in what
year did you move to the United States?
What language do you normally speak at home?

YEAR MOVED TO U.S.

English
Another language. Please specify other language:

________________________________________

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Cervical Cancer Study: Patient Survey

Page 3

PART B: Health and Clinic History
Following are some questions about this clinic and getting Pap tests done. Please write in or check (9)
the best answer.

B1.

Including this visit, about how many times have
you gone to this clinic for your health care in the
past 12 months? Do not include visits for friends
or family members.

1 time
2–4 times
5–10 times
More than 10 times

B2.

Is this clinic the one you use most of the time
when you need to see a doctor?

Yes
No

B3.

Have you visited other clinics or doctors’ offices in
the past 12 months for your health care?

Yes
No

B4.

In your entire life, about how many times have you
had a Pap test?

Never
1 time
2–4 times
5–10 times
More than 10 times

B5.

Of these, about how many times have you had a
Pap test at this clinic?

Never
1 time
2–4 times
5–10 times
More than 10 times

B6.

Do you agree or disagree that the Pap test is used
to check for:

Agree

Disagree

Not Sure

Pregnancy ............................................................

HIV/AIDS..............................................................

Gonorrhea ............................................................

Chlamydia ............................................................

Human Papillomavirus (HPV) ..............................

Cervical cancer ....................................................

Vaginal cancer .....................................................

Yeast infections....................................................

Vaginal infections .................................................

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Cervical Cancer Study: Patient Survey

Page 4

If you have never had a Pap test, please go to Question C1.
B7.

How often do you get Pap tests?

Please 9 only one.

B8.

Were you ever told that your Pap test was not
normal?

How long ago was your last abnormal Pap
test?

More often than once a year
Once a year
Once every 2 or 3 years
Less often than once every 3 years
Today is my
Go to Question C1.
first Pap test

Yes
No
I’m not sure

Go to Question B9.

Years ago
Or
Months ago

B9.

After getting your last Pap test, when were you
told to come back for your next Pap test?

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As soon as possible
6 months
1 year
2 years
3 years
No one said when to come back again
I’m not sure

Cervical Cancer Study: Patient Survey

Page 5

PART C: Health Behaviors
Some of the questions may be personal. Please answer as best as you can.

C1.

C2.

C3.

About how old were you when you had vaginal
sex for the first time?

YEARS OLD

About how many different partners have you ever
had vaginal sex with in your entire life?

# PARTNERS

How many different people did you have sex with
in the last 12 months?

LAST 12 MONTHS

C4.

Have you ever been told that you had a sexually
transmitted infection or STD?

Yes
No
I’m not sure

C5.

Have you ever been told that you had genital
warts?

Yes
No
I’m not sure

C6.

Do you smoke cigarettes?

Yes
No

How many days a week do you smoke
cigarettes?

DAYS PER WEEK

How many cigarettes do you smoke each
day?

CIGS PER DAY

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Go to Question D1.

Cervical Cancer Study: Patient Survey

Page 6

PART D: Your Opinions About HPV and Pap Tests
D1.

D2.

Before today, have you ever heard of HPV? HPV
stands for Human Papillomavirus.

Yes
No

Go to Question E1.

Please 9 all of the sources below where you learned about HPV.

D3.

Internet
Magazines
Pamphlets
Books
Health Department
Telephone Hotline
Partner
Friends
Family

Co-workers
Teacher
Health Care Provider
Family Planning Clinics
Planned Parenthood
Medical books/medical journals
Television
Radio
Other. Please specify: __________________________________

Please mark whether you agree, disagree, or are not sure about the following statements.
We are interested in your opinions and what
you may have heard about HPV.

Agree

Disagree

Not Sure

There are many types of HPV..............................

HPV causes HIV/AIDS .........................................

Antibiotics can cure HPV......................................

You can always tell when someone else has
HPV ......................................................................

HPV can cause abnormal Pap tests ....................

Only women get HPV...........................................

HPV causes herpes .............................................

HPV affects your ability to get pregnant...............

HPV is a virus.......................................................

Once you get HPV, you always have it................

There are types of HPV that cause genital warts

HPV can be cured ................................................

You can get HPV from toilet seats .......................

HPV is a sexually transmitted infection................

There are types of HPV that cause cervical
cancer...................................................................

HPV may go away by itself ..................................

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Cervical Cancer Study: Patient Survey

D4.

Agree

Disagree

Not Sure

You can get HPV through poor personal
hygiene.................................................................

Even if you do not see a wart, you can still give
HPV to someone else ..........................................

Using a condom will lower the chance of giving
HPV to someone else ..........................................

Lots of people have HPV .....................................

You can have HPV for a long time without
knowing it .............................................................

You can have more than one type of HPV...........

When you had your last Pap test, did you get an
HPV test at the same time?

D5.

Page 7

What was the result of your HPV test?

Yes
No
Don’t Know
Today is my first
Pap test
HPV-Positive
HPV-Negative
I’m not sure

Go to Question D5.

How good or bad did you feel after getting
the result of your HPV test?

Very good
Somewhat good
Neither good nor bad
Somewhat bad
Very bad

How worried or relieved did you feel after
getting the result of your HPV test?

Very worried
Somewhat worried
Neither worried nor relieved
Somewhat relieved
Very relieved

How happy or unhappy did you feel after
getting the result of your HPV test?

Very happy
Somewhat happy
Neither happy nor unhappy
Somewhat unhappy
Very unhappy

Have you ever been told by a health care provider
that you had HPV infection?

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Yes
No
Don’t know

Cervical Cancer Study: Patient Survey

Page 8

D6.

We’d like your opinion about getting an HPV test
along with your Pap test today. How good or bad
will it be to get an HPV test today?

Very good
Somewhat good
Neither good nor bad
Somewhat bad
Very bad

D7.

How useless or useful will it be to get an HPV test
today?

Very useless
Somewhat useless
Neither useless nor useful
Somewhat useful
Very useful

D8.

How comforting or worrying will it be to get an
HPV test today?

Very comforting
Somewhat comforting
Neither comforting nor worrying
Somewhat worrying
Very worrying

D9.

How wise or foolish will it be to get an HPV test
today?

Very wise
Somewhat wise
Neither wise nor foolish
Somewhat foolish
Very foolish

D10.

Please 9 one box on each line to indicate how much you agree or disagree with the following
statements.
Getting an HPV test with your Pap
test:

D11.

Strongly
Agree

Somewhat
Agree

Neither/
Not sure

Somewhat
Disagree

Strongly
Disagree

Will give you peace of mind ................

Will tell you whether you need to
worry if your Pap is abnormal .............

Will be an unnecessary extra cost ......

Is something your doctor thinks you
should have.........................................

Will give you the best care available...

If your health care provider recommends that you
have your next Pap test in 3 years, how likely are
you to wait that long?

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Very unlikely
Somewhat unlikely
Neither unlikely nor unlikely/not sure
Somewhat likely
Very likely

Cervical Cancer Study: Patient Survey

Page 9

D12.

How good or bad would it be to wait 3 years for
your next Pap if that is what your health care
provider recommends that you do?

Very good
Somewhat good
Neither good nor bad
Somewhat bad
Very bad

D13.

How useless or useful would it be to wait 3 years
for your next Pap?

Very useless
Somewhat useless
Neither useless nor useful
Somewhat useful
Very useful

D14.

How comforting or worrying would it be to wait 3
years for your next Pap?

Very comforting
Somewhat comforting
Neither comforting nor worrying
Somewhat worrying
Very worrying

D15.

How wise or foolish would it be to wait 3 years for
your next Pap?

Very wise
Somewhat wise
Neither wise nor foolish
Somewhat foolish
Very foolish

D16.

Please 9 one box on each line to indicate how much you agree or disagree with the following
statements.
Waiting 3 years for your next Pap
test:

Strongly
Agree

Somewhat
Agree

Neither/
Not sure

Somewhat
Disagree

Strongly
Disagree

Would save you money.......................

Would cause you to worry about
getting cervical cancer ........................

Would give you peace of mind............

Is something your doctor thinks you
should do.............................................

Would mean you would not get other
health care that you need when you
need it..................................................

Would increase your chance of getting
cervical cancer ....................................

Would save you time...........................

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Cervical Cancer Study: Patient Survey

Page 10

PART E: Use and Cost of Health Care Services
If today is your first visit to this clinic, please answer as best you can based on today’s experience so far.
E1.

E2.

E3.

E4.

When you come to this clinic to see a health care
provider, how much time do you usually spend at
the clinic? Count from the time you arrive at the
clinic until the time you leave.
Thinking about your travel time, how much time
do you usually spend getting to the clinic and
getting home again?
Do you usually get to the clinic by car?

When you use a car, how many miles do you
drive to get to the clinic and back?
A.

E5.

How much do you pay?

Do you usually get to the clinic by bus, train, taxi,
or ferry?

E6.

Do you usually pay to park?

How much do you pay?

When you go to the clinic, do you need someone
else to go with you?

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HOURS

MINUTES

HOURS

MINUTES

Yes
No

Go to Question E5.

# OF MILES

Yes
No

Go to Question E5.

Amount paid: $___________________________

Yes
No

Go to Question E6.

Amount paid: $___________________________

Yes, all of the time
Yes, most of the time
Yes, some of the time
No

Cervical Cancer Study: Patient Survey

E7.

Do you need to pay for child care for your children
so that you can go to the clinic?

Page 11

E8.

How much do you have to pay for child care
when you go to the clinic?

Are you currently employed for wages, either full
or part time?

Yes, all of the time
Yes, most of the time
Yes, some of the time
A little of the time
No, I don’t need
to pay for it
No, I don’t have
young children

Go to
Question E8.

Amount paid: $___________________________

Yes
Self-employed

Go to Question E11.

E9.

How often do you need to take time off from work
to go to the clinic?

All of the time
Most of the time
Some of the time
A little of the time
None of the time

E10.

What do you earn per hour on your current job?
Include tips, bonuses, and commissions (before
deducting taxes).

Less than $7.50 per hour
$7.50–$9.99 per hour
$10–$14.99 per hour
$15–$19.99 per hour
$20–$29.99 per hour
$30 per hour or more

What is your current employment status?
Please 9 only one.

Out of work for less than 1 year

E11.

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Out of work for more than
1 year
Homemaker
Student
Retired
Unable to work

Go to
Question
E13.

Cervical Cancer Study: Patient Survey

Page 12

E12.

What did you earn per hour on your most recent
job? Include tips, bonuses, and commissions
(before deducting taxes).

E13.

We would like to ask you a few questions about the amount of money that you spend for health care (for
example, clinic visits, laboratory tests, prescription medicines, emergency room visits, and hospital
stays). Only include what you spend for yourself and do not include what you may spend for other
family members.
Will you need to pay for anything for today’s clinic
visit?

E14.

How much will you have to pay?

Is this the same amount that you usually pay
for a clinic visit?

What do you usually pay for a visit?

In the past year, have you paid for any visits to
this clinic?

E15.

What is the total that you have paid during
the year?

Less than $7.50 per hour
$7.50–$9.99 per hour
$10–$14.99 per hour
$15–$19.99 per hour
$20–$29.99 per hour
$30 per hour or more

Yes
No
Don’t know

Go to Question E14.

Amount paid: $___________________________

Yes
No
Don’t know

Go to Question E14.

Amount paid: $___________________________

Yes
No
Don’t know

Go to Question E15.

Yearly total: $ ___________________________

In the past year, have you paid for other health
care expenses for yourself? This includes
prescription medicine, hospital visits, emergency
room visits or visits to other clinics or doctors’
offices.

Yearly total: $ ___________________________

What is the total that you have paid during
the year?

Yes
No
Don’t know

Go to End of Survey.

Thank you very much for filling out this survey.
Please put it in the attached envelope
and return it to the Study Coordinator.
G:\Controlled Files\PD\FG601906-01\SAQ\HPV Baseline SAQ Complete v2.doc

File Type	application/pdf
File Title	Microsoft Word - HPV Baseline SAQ Complete v2.doc
Author	TREECEM
File Modified	2009-01-21
File Created	2009-01-21