Young Sisters Initiative (YSI) Program
Post-Use Survey
Form Approved
OMB No:
0920-XXXX
Expiration
Date: XX/XX/XXXX
Young Sisters Initiative (YSI) Program
Post-Use Survey
Public reporting burden for this collection of information is estimated to average 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, Mailstop D74, Atlanta, GA 30333; ATTN: PRA 0920-XXXX. Do not return the completed form to this address.
YOUNG SISTERS INITIATIVE PROGRAM
POST-USE SURVEY
Website Welcome language – Welcome and thank you for visiting the Young Sisters Initiative: A Guide to a Better You Program! The YSI program is targeted to African American young breast cancer survivors to provide you with information and resources to help you during your cancer journey. The YSI program provides you with information on coping with fear of recurrence, fertility, and sexual dysfunction); ways to cope with psychosocial and reproductive health issues; and ways to cope with the side effects of breast cancer treatment.
You previously agreed to complete a brief survey after accessing the YSI program. The following survey asks you a series of questions about your experiences with the YSI program.
What type of YSI program user are you?
Breast cancer survivor
Spouse/family member
Caregiver
Health care provider
Other (please specify_____)
What is your current age? _____
Are you Hispanic or Latina?
Yes
No
Which of these groups represents your race? Select one or more.
Black or African American
White
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Are you a breast cancer survivor?
Yes
No
What was the date of your breast cancer diagnosis? _____
Were you diagnosed with breast cancer on or before your 45th birthday?
Yes
No
What was the stage of your breast cancer at diagnosis?
Stage I
Stage II
Stage III
Stage IV
Other (please specify_____)
What are your overall general thoughts about the YSI program?
[Text box response]
On a scale of 1-5, how easy was it to access the YSI program?
Very difficult to access
Difficult to access
Neutral
Easy to access
Very easy to access
What helped you be able to access the YSI program?
[Text box response]
What were the barriers to your access the YSI program?
[Text box response]
On a scale of 1-5, how easy was it to navigate the YSI program?
Very difficult to navigate
Somewhat difficult to navigate
Neutral
Easy to navigate
Very easy to navigate
What helped you be able to navigate the YSI program?
[Text box response]
What were the barriers to your navigating the YSI program?
[Text box response]
On a scale of 1-5, how easy was it to follow the structure of the YSI web site?
Very difficult to follow
Somewhat difficult to follow
Neutral
Easy to follow
Very easy to follow
What are your overall thoughts about YSI program content?
[Text box response]
On a scale of 1-5, how useful was the YSI content?
Very unuseful
Somewhat unuseful
Neutral
Somehwat useful
Very useful
How the YSI program was content useful to you on the YSI program web site?
[Text box response]
On a scale of 1-5, how helpful are the resources on the YSI program web site? (e.g., on the Other Resources Page)?
Very unhelpful
Somewhat unhelpful
Neutral
Somewhat helpful
Very helpful
On a scale of 1-5, how satisfied were you with the YSI program?
Very unsatisfied
Somewhat unsatified
Neutral
Somewhat satisfied
Very satisfied
What is the most helpful information you encountered on the YSI program website?
About Us information [skips to question 24]
Word animation video [skips to question 24]
YSI Program Workbook
Resources [skips to question 24]
Survivor videos [skips to question 24]
Contact Us form [skips to question 24]
Which section of the YSI Program workbook was most helpful to you?
Section 1: Breast Cancer, Treatment, and Aftercare
Section 2: Breast Cancer Risk and Your Family
Section 3: Emotional Health and Wellness
Section 4: Living with Breast Cancer: Family, Friends, and Workplace Issues
Section 5: Premature Menopause and Breast Cancer
Section 6: Health and Beauty
Section 7: Breast Cancer, Sexuality, and Dating
Section 8: Fertility, Pregnancy, and Motherhood After Breast Cancer
What is the least helpful information you encountered on the YSI program website?
About Us information [skips to question 26]
Word animation video [skips to question 26]
YSI Program Workbook
Resources [skips to question 26]
Survivor videos [skips to question 26]
Contact Us form [skips to question 26]
Which section of the YSI Program workbook was most helpful to you?
Section 1: Breast Cancer, Treatment, and Aftercare
Section 2: Breast Cancer Risk and Your Family
Section 3: Emotional Health and Wellness
Section 4: Living with Breast Cancer: Family, Friends, and Workplace Issues
Section 5: Premature Menopause and Breast Cancer
Section 6: Health and Beauty
Section 7: Breast Cancer, Sexuality, and Dating
Section 8: Fertility, Pregnancy, and Motherhood After Breast Cancer
On a scale of 1-5, how likely are you to return to the YSI program for information and/or support?
Very unlikely
Somewhat unlikely
Neutral
Somewhat likely
Very likely
On a scale of 1-5, how likely are you to recommend the YSI program to others?
Very unlikely
Somewhat unlikely
Neutral
Somewhat likely
Very likely
Thank you for completing this survey.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | C.Ashani-Turbes |
File Modified | 0000-00-00 |
File Created | 2021-01-30 |