Form 15 Participant Information Form

OMB XXX-XXXX

PARTICIPANT INFORMATION FORM

We would like to learn a little more about you. We will not use your name with this information. If you do not want to answer a question, you can skip it and move to the next item. All of your answers will be kept confidential. DO NOT WRITE YOUR NAME ON ANY PART OF THIS FORM. Please let us know if you have any questions.

1. Are you...?

• Male

• Female

2. What is your current age?

• 20 - 29

• 30 - 39

• 40 - 49

• 50 - 59

• 60 - 69

• 70

3. What is your ethnicity?

• Hispanic or Latino

• Not Hispanic or Latino

4. What is your race? (Check all that apply)

• White

• Black or African-American

• Asian

• Native Hawaiian/Pacific Islander

• American Indian/Alaska Native

4

Are you a:

• PCP

• Specialist

• Other type of health care provider (please specify):

______________________

. What is your connection with the Patient Navigator Program?

• Health care provider within clinic system 

• Health care provider outside of clinic system 

• Social service support provider within clinic system

• Social service support provider outside of clinic system

• Administrator within clinic system

• Health education services provider

• Translator

• Clinical trials liaison

• Other (please specify): ______________________

5. How often have you worked with the Patient Navigator program? (Please check one)

• Less than 3 times

• Between 3 - 6 times

• More than 6 times

• I don’t know/I’m not sure

THANKS FOR YOUR HELP!