Survey Items by Respondent Type

Web-based Survey Items by Respondent Type

Survey Item

Respondent Type

Grantee

Partner

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 17

X

X

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: ___________

X

X

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

 Yes  Grantees go to Question 4 [Partners skip to Question 6]

 No  Skip to Question 6

X

X

4. Please select your state’s approach to adopting the Cancer Survivorship module.

 My state adopted the entire Cancer Survivorship module at the onset.

 My state is doing a phased adoption of the Cancer Survivorship module, starting with a subset of questions.

 My state has adopted a subset of questions with no current plans to add remaining questions.

□ My state has not adopted any Cancer Survivorship module questions.

X

5. Please indicate which of the following questions from the Cancer Survivorship module were included in your state’s most recent BRFSS. Select all that apply.

 All of the questions in the module were included.

 Question 1. How many different types of cancer have you had?

 Question 2. At what age were you told that you had cancer?

 Question 3. What type of cancer was it?

 Question 4. Are you currently receiving treatment for cancer? By treatment, we mean surgery, radiation therapy, chemotherapy, or chemotherapy pills.

 Question 5. What type of doctor provides the majority of your health care?

 Question 6. Did any doctor, nurse, or other health professional EVER give you a written summary of all the cancer treatments that you received?

 Question 7. Have you EVER received instructions from a doctor, nurse, or other health professional about where you should return or who you should see for routine cancer check-ups after completing your treatment for cancer?

 Question 8. Were these instructions written down or printed on paper for you?

 Question 9. With your most recent diagnosis of cancer, did you have health insurance that paid for all or part of your cancer treatment?

 Question 10. Were you EVER denied health insurance or life insurance coverage because of your cancer?

 Question 11. Did you participate in a clinical trial as part of your cancer treatment?

 Question 12. Do you currently have physical pain caused by your cancer or cancer treatment?

 Question 13. Is your pain currently under control?

X

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

 Yes

 No  Skip to Question 8

X

X

7. 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:________________________________________________

X

X

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

 Yes

 No  Skip to Question 10

X

X

9. 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:________________________________________________

X

X

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

 None

 Other:________________________________________________

X

X

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

 Populated with cancer registry data

 Populated with electronic health records

 Other:_____________________

X

12. How many providers in your state do you estimate use Electronic Health Record data to populate Survivorship Care Plans? [open text]

X

13. How many providers do you estimate use cancer registry data to populate Survivorship Care Plans? [open text]

X

14. How many providers are not using either Electronic Health Record or cancer registry data to populate Survivorship Care Plans? [open text]

X

15. What percentage of Survivorship Care Plans in your state are generated using surveillance data (e.g., cancer registry)?

 0% (None)

 1-25%

 26-50%

 51-75%

 76-99%

 100%

 Don’t know

X

16. . What percentage of Survivorship Care Plans in your state are generated using individual data (e.g., electronic health records)?

 0% (None)

 1-25%

 26-50%

 51-75%

 76-99%

 100%

 Don’t know

X

Communication, Education and Training

17. Have you conducted any provider education or trainings?

 Yes

 No

X

18. Have you participated in (either by organizing or attending) provider education or training?

 Yes

 No  Skip to Question 23

X

19. Of the providers you’ve contacted, what percentage participated in your education opportunities? [open text]

X

20. 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:__________________________________________		

X

X

21. What types of communication activities have you implemented for providers? Select all that apply.

 Communication campaign materials

 Email updates/newsletters

 In-person patient navigation training

 Independently developed education materials

 Printed materials such as fact sheets or educational one-pagers

 Promoting the e-learning series and the use of Survivorship Care Plans (e.g., via one-on-one meetings, presentations at staff meetings)

 Social media

 Webinars or other CME learning activities

 Other:_____________________________________

X

22. What types of communication activities have you done to educate cancer survivors about Survivorship Care Plans? Select all that apply.

 Email updates/newsletters

 One-on-one meetings

 Phone calls

 Printed materials

 Social media

 Webinars

 Other:____________________________________

X

23. 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:__________________________________________		

X

X

Enhanced Partnerships

24. What types of resources have you / your organization provided to support the Cancer Survivorship program’s implementation? Please 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:___________________________________________

X

25. Please indicate which of the following 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:____________________________________________		

X

26. What type of new patient populations are you able to reach through your work with partners? 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)

 Veterans

 Other:_____________________________________________________

X

27. Because of partner collaborations, has your reach expanded to any of the following cancer survivor groups?

 No expansion resulted

 Breast

 Colorectal

 Lung

 Melanoma

 Prostate

 Ovarian/cervical (gynecological)

 Other:_______________________________________________

X

28. 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:_____________________________________________________

X

29. What type(s) of cancer do your patient populations most commonly face?

 Breast

 Colorectal

 Lung

 Melanoma

 Prostate

 Ovarian/cervical (gynecological)

 Other:_______________________________________________

X

Challenges and Facilitators

30. What are some key factors that have led to successful partnerships with other DP15-1501 grantees (e.g., history of working together, common goals, common target audience/patient population, partners’ thought leadership/subject matter expertise)? [open text]

X

31. What are some key factors that have led to successful partnerships with external partners (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]

X

32. 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]

X

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

X

34. What have been the primary challenges in your partnerships with external partners (e.g., communication, competing priorities/interests, lack of common goal, staffing turnover, time commitment)? [open text]

X

35. 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]

X

Respondent Background

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

X

X

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

 Yes

 No

X

X

38. What is the name of your organization? __________

X

39. Are you a healthcare provider?

 Yes

 No  Skip to Question 41

X

40. What is your healthcare specialty?

 Medical Oncology

 Radiation Oncology

 Gynecologic Oncology

 Urologist

 General Surgery

 Family Medicine

 General practitioner /Internal Medicine

 Other: _______________

X

41. What is your role at your organization?

[Drop-down list for grantees: DP15-1501 program coordinator; DP15-1501 program manager; Other:__________________]

X

42. What is your role at your organization?

[Drop-down list for partners: Coalition member; Hospital Administrator; Patient Navigator; Provider; Other:______________]

X