Form 0920- Ovarian Cancer Survivorship Survey

Understanding the Needs of Ovarian Cancer Survivors

OCS Att 3b web-based questionnaire Final

Att 3b_Web-based Questionnaire

OMB: 0920-1314

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INTRO

SCREENER1

SCREENER2

SCREENER3

INELIGIBLE

INFORMED CONSENT

INTRO2/DIAG_AGE

DIAG_HOW

SYMPTOM_A THROUGH SYMPTOM_F

DIAG_TIME

STAGE

DR_WHICH

CANC_OTH

CANC_TYPE/CANC_AGE

INTRO3/SURGERY

DR_SURG

TRAVEL_SURG

TRTMNT_A THROUGH TRTMNT_F

TRAVEL_CHEMO

CLINICTRIAL

TRIAL_PART

NO_PART

REASON

RECENT

TRTMT_CURR

ER_EVER

EFFECTS_A THROUGH EFFECTS_E

RECUR

RECUR_AGE

METASTASIS

META_AGE

REMISSION

INTRO4

TXSYMPTOM_A THROUGH TXSYMPTOM_E

EXPBEFORE

INTERFERE

TALK_SYMP

TREAT_A THROUGH TREAT_G

NEUROP

SINCE_A THROUGH SINCE_J

BEFORE

ACTIVITIES

SYMPTALK

COGNITIVE

WGT_CHG

WGT_REC

WEIGHT

HEIGHT_FT/HEIGHT_IN

PSTWK_A THROUGH PSTWK_F

PSTWK_G THROUGH PSTWK_N

PSTWK_ O THROUGH PSTWK_U

INTRO5

RISK_TALK

FAM_OVAR

OVAR_NUM

FAM_BREAST

BREAST_NUM

UNDER50

MALE_BREAST

GENETIC_REC

GENETIC_YN

GENETIC_WHEN

GENETIC_WHO

GENETIC_FAM

BRCA_YN

BRCA_RESULTS

INFLUENCE

NOTEST

BRCA_FAM

BRCA_DESCNT

INTRO6

SIDEEFFECTS_A THROUGH SIDEEFFECTS_K

INTRO7

RELATIONS

SERVICES_A THROUGH SERVICES_J AND HELPFUL_A THROUGH HELPFUL_J

NOSUPPORT

RELY_A THROUGH RELY_P

INTRO8

INSURE_YN

INSURE_TYPE

INSREF_APPT

INSREF_OPIN

INSREF_TEST

INSREF_MED

STAYJOB

LOSE_CANC

UNINSURED

DENY_INS

INTRO9

EMPLOY

EMP_TYPE

LEAVE_YN

LEAVE_TYPE

WORKAFTER_YN

WORKTX_AFTER

TRTMNT_AFTER

DISCRIM

INTRO10

FINANCES

BORROW

BANKRUPT

SACRIFICE

MEDBILLS

UNABLE

OUTOFPOCKET

INTRO11

OTHMED_A THROUGH OTHMED_M/DIAG_A THROUGH DIAG_M

DEPRESS

DEPRESS_BDA

DEPRESS_CURR

DEPRESS_RX

ANXIETY

ANXIETY_BDA

ANXIETY_CURR

ANXIETY_RX

PAIN_OTC

PAINMED

PAINMED_WHY

PAINMED_BDA

CHOLEST

CHOLEST_BDA

CHOLES_CURR

BP_EVER

BP_BDA

BP_CURR

INSULIN

INSULIN_BDA

INSULIN_CURR

SLEEP

SLEEP_BDA

SLEEP_CURR

INTRO12

GLOBAL01 THROUGH GLOBAL05, GLOBAL 09

GLOBAL06

GLOBAL10

GLOBAL08

GLOBAL07

SLEEP_SATIS

PAST4_A THROUGH PAST4_J

INTRO14

SCHOOL

MARITAL

ETHNICITY

ETH_GROUP

RACE

EMPLOY_CURR

HI_TYPE

NOHI_12MOS

CHILDREN

CHILD_NUM

UNDER18

INCOME

STATE

ZIP_CODE

INCENT2

WEBINEM1

WEBINEM2

INC_ADDRESS

NETWORK1

NETWORK2

NETWORK3

NETWORK4

WOMAN_1

WOMAN_2

WOMAN_3

THANKYOU


File Typeapplication/pdf
AuthorStephanie Poland
File Modified2019-03-04
File Created2019-03-01

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