Partner Survey

5/14/18

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/20XX

Cancer Survivorship Assessment

Web-based Partner Survey

Public reporting burden of 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-XXXX).

CANCER SURVIVORSHIP ASSESSMENT WEB-BASED SURVEY

Introduction

CDC has funded RTI to assess the DP15-1501 Cancer Survivorship program. As part of this assessment, RTI is administering a web-based survey to NCCCP DP15-1501 grantees and their partners. The purpose of the survey is to gather your perspectives on:

• increasing utilization of surveillance data to inform program planning,

• planning, implementing, and sustaining evidence-based strategies to increase knowledge of cancer survivor needs, and

• enhancing partnerships that can facilitate and broaden program reach

We’d also like your perspective on the challenges, facilitators, and lessons learned with regard to implementing these activities.

The survey should take less than 20 minutes to complete. Your answers will not be linked to your name and there are minimal risks to you from participation. We will use some quotes in reports, but quotes will not be attributed to an individual or his/her organization. We want to assure you that we will not quote you by name. All of the survey data will be kept secure on RTI’s network.

Your insights will be used by CDC to improve efforts to support NCCCP programs in implementing evidence-based and promising strategies to improve cancer survivorship care. After completing the survey, you may enter your email address for a chance to win a $50 Amazon gift card.

This research protocol has been reviewed by RTI’s Institutional Review Board (IRB).

Clicking on the ‘Next’ button below indicates that you have read the above information and you agree to participate in the survey.

Surveillance Data

1. Have you worked on supporting the use of surveillance data (e.g., Behavioral Risk Factor Surveillance System [BRFSS], Electronic Health Records) among providers or coalition members?

 Yes

 No  Skip to Question 10

2. In what ways are you using surveillance data to inform cancer survivorship interventions (program planning)? Select all that apply.

 identify target populations

 identify cancer survivors’ needs

 populate Survivorship Care Plans

 monitor survivorship outcomes

 Other, please describe: ___________

3. Have you been involved in efforts to add the Cancer Survivorship module to your state’s Behavioral Risk Factor Surveillance System (BRFSS)?

 Yes

 No

4. Have you been involved in efforts to use surveillance data (e.g. cancer registry data) in Survivorship Care Plans?

 Yes

 No  Skip to Question 6

5. In what ways have you helped health systems commit to incorporating surveillance data (e.g. cancer registry data) into Survivorship Care Plans (SCPs)? Select all that apply.

 Meeting with providers to get buy-in

 Meeting with hospital administrators to get buy-in

 Coordinating a formal training for providers

 Coordinating a formal training for hospital administrators

 Providing on-site technical assistance

 Providing educational materials/template to providers that shows how to incorporate

surveillance data into SCPs

 Other:________________________________________________

6. Have you been involved in efforts to use individual data (e.g. electronic health records) in Survivorship Care Plans?

 Yes

 No  Skip to Question 8

7. In what ways have you helped health systems commit to incorporating individual data (e.g., electronic health records) into Survivorship Care Plans (SCPs)? Select all that apply.

 Meeting with providers to get buy-in

 Meeting with hospital administrators to get buy-in

 Coordinating a formal training for providers

 Coordinating a formal training for hospital administrators

 Providing on-site technical assistance

 Providing educational materials/template to providers that shows how to incorporate

individual data into SCPs

 Other:________________________________________________

8. What other data have you incorporated into Survivorship Care Plans (aside from cancer registry and EHR)?

 None

 Other:________________________________________________

9. How are Survivorship Care Plans generated at your organization? Select all that apply.

 Populated with cancer registry data

 Populated with electronic health records

 Other:_____________________

Communication, Education and Training

10. Please indicate whether you have participated in or organized any of the following educational / training opportunities.

	Yes	No
National Cancer Survivorship Resource Center’s (NCSRC’s) E-learning series		
In-house presentation during clinical staff meetings		
In-house presentation during grand rounds		
Other:__________________________________________		

11. Have you contributed to the development of any of the following educational resources for cancer survivors?

	Yes	No
Information about follow-up care or screenings		
Information about emotional support		
Information about mental health
Information about physical health (e.g., nutrition, exercise, side effects from treatment)		
Information about sexual health (e.g., intimacy, fertility)		
Information about work concerns / financial support / health insurance coverage		
Information about using Survivorship Care Plans		
Other:__________________________________________		

Enhanced Partnerships

12. What types of resources have you / your organization provided to support the DP15-1501 Cancer Survivorship program’s implementation? Select all that apply.

 Time

 Meeting space

 Materials

 Hiring of new staff

 Recruitment of volunteers

 In-kind funding

 Additional grant funding (not including CDC DCPC)

 Thought leadership (i.e., an individual that is recognized as an authority in a specialized field and whose expertise is sought out)

 Meeting facilitation

 Other:___________________________________________

13. Please indicate which of the following DP15-1501 cancer survivorship activities you have participated in.

	Yes	No
Adding the Cancer Survivorship module to your state’s BRFSS		
Auto-populating Survivorship Care Plans with EHR data		
Adopting or expanding Patient Navigator programs for survivors		
Promoting / disseminating National Cancer Survivorship Resource Center resources (e.g., E-Learning series)		
Developing educational materials for cancer survivors		
Disseminating educational materials for cancer survivors		
Other:____________________________________________		

14. What type(s) of patient populations are you able to reach through your work at your organization? Select all that apply.

 Adolescent / young adult

 African American

 Asian

 At-risk due to family history

 Disabled

 Hispanic

 LGBT

 Low-income

 Metastatic

 Native American / American Indian

 Pediatric

 Rural

 Seniors (age 65+ years)

 Under-insured / uninsured Veterans

 Other:_____________________________________________________

15. What are the most common types of cancer that your patient population faces? Please rank, from 1 (most common) to 6 (least common).

[1-digit numeric field open text] Breast

[1-digit numeric field open text] Colorectal

[1-digit numeric field open text] Lung

[1-digit numeric field open text] Melanoma

[1-digit numeric field open text] Prostate

[1-digit numeric field open text] Ovarian/cervical (gynecological)

[1-digit numeric field open text] Other:_______________________________________________

Challenges and Facilitators

16. What are some key factors that have led to a successful partnership with your DP15-1501 grantee (e.g., history of working together, physical proximity of offices, common goals, common target audience/patient population, partners’ thought leadership/subject matter expertise)? [open text]

17. What have been the primary challenges in your partnership with your DP15-1501 grantee (e.g., communication, competing priorities/interests, lack of common goal, staffing turnover, time commitment)? [open text]

Respondent Background

18. In what state are you located? [Drop-down list: Indiana, Kansas, Louisiana, Michigan, South Dakota, Washington]

19. Are you employed by your state’s cancer registry?

 Yes

 No

20. What type of organization do you work for?

 Cancer coalition

 Clinic / satellite office

 Health-focused nonprofit (e.g., American Cancer Society)

 Health Department (State or Local)

 Health insurance provider

 Hospital

 Private practice

 Other: ___________________________

21. Are you a healthcare provider?

 Yes

 No  Skip to Question 23

22. What is your healthcare specialty?

 Medical Oncology

 Radiation Oncology

 Gynecologic Oncology

 Urologist

 General Surgery

 Family Medicine

 General practitioner /Internal Medicine

 Other: _______________

23. What is your role at your organization?

 Coalition member

 Hospital Administrator

 Patient Navigator

 Provider

 Other: __________________

If you would like to be entered into a raffle for a $50 Amazon gift card, please provide your email address here: __________________________________________

THANK YOU FOR YOUR TIME!

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