Cancer Survivorship Survey for Northwest Tribal Healthcare Providers and Cancer Prevention Advocates

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* 1. Where do you work?

A Tribal healthcare facility

Within a Tribal community

Urban Indian Health Organization

Other (please specify)

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* 2. What is your professional title?

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* 3. What is your role in cancer prevention and control within your community/clinic?

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* 4. If a patient has an abnormal cancer screening result, what step do you usually take next?

Repeat the test

Refer for diagnostic testing

Other (please specify)

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* 5. What cancer treatment center do you refer cancer patients to?

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* 6. What are the most common cancers that you see in your practice? Please select the top 3

Breast

Colorectal

Gynecologic

Liver

Lung

Prostate

Other (please specify)

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* 7. How do you receive information about the care a patient referred for cancer treatment receives? (select all that apply)

Oncologist sends written survivorship care plan

Patient provides written survivorship care plan

Request cancer treatment information from provider

Patient verbally shares cancer treatment information

Don’t usually receive information

Other (please specify)

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* 8. How do you promote cancer screenings in your clinic? (select all that apply)

Our providers suggest patients get cancer screening during clinic visits

Our staff let patients know that they are due for cancer screenings

Distribute flyers in community (health fairs, library, etc.)

Newspaper

Magazine

Radio

Television

Social media

Other (please specify)

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* 9. Please rank the resources our program can provide for increasing cancer screening in your patients from most helpful to least helpful

	Not at all helpful	Somewhat helpful	Moderately helpful	Very helpful	Extremely helpful
Technical assistance and training on cancer interventions that work	Technical assistance and training on cancer interventions that work Not at all helpful	Technical assistance and training on cancer interventions that work Somewhat helpful	Technical assistance and training on cancer interventions that work Moderately helpful	Technical assistance and training on cancer interventions that work Very helpful	Technical assistance and training on cancer interventions that work Extremely helpful
Data that describes the burden of cancer	Data that describes the burden of cancer Not at all helpful	Data that describes the burden of cancer Somewhat helpful	Data that describes the burden of cancer Moderately helpful	Data that describes the burden of cancer Very helpful	Data that describes the burden of cancer Extremely helpful
Bringing people together to talk about how we can decrease the burden of cancer	Bringing people together to talk about how we can decrease the burden of cancer Not at all helpful	Bringing people together to talk about how we can decrease the burden of cancer Somewhat helpful	Bringing people together to talk about how we can decrease the burden of cancer Moderately helpful	Bringing people together to talk about how we can decrease the burden of cancer Very helpful	Bringing people together to talk about how we can decrease the burden of cancer Extremely helpful
Providing seed money to implement interventions in the cancer plan	Providing seed money to implement interventions in the cancer plan Not at all helpful	Providing seed money to implement interventions in the cancer plan Somewhat helpful	Providing seed money to implement interventions in the cancer plan Moderately helpful	Providing seed money to implement interventions in the cancer plan Very helpful	Providing seed money to implement interventions in the cancer plan Extremely helpful
Ensuring that we have an up-to-date and comprehensive cancer plan	Ensuring that we have an up-to-date and comprehensive cancer plan Not at all helpful	Ensuring that we have an up-to-date and comprehensive cancer plan Somewhat helpful	Ensuring that we have an up-to-date and comprehensive cancer plan Moderately helpful	Ensuring that we have an up-to-date and comprehensive cancer plan Very helpful	Ensuring that we have an up-to-date and comprehensive cancer plan Extremely helpful
Providing resources like cancer ads and posters	Providing resources like cancer ads and posters Not at all helpful	Providing resources like cancer ads and posters Somewhat helpful	Providing resources like cancer ads and posters Moderately helpful	Providing resources like cancer ads and posters Very helpful	Providing resources like cancer ads and posters Extremely helpful
Providing cancer training with CMEs	Providing cancer training with CMEs Not at all helpful	Providing cancer training with CMEs Somewhat helpful	Providing cancer training with CMEs Moderately helpful	Providing cancer training with CMEs Very helpful	Providing cancer training with CMEs Extremely helpful
Survivorship care visit checklist	Survivorship care visit checklist Not at all helpful	Survivorship care visit checklist Somewhat helpful	Survivorship care visit checklist Moderately helpful	Survivorship care visit checklist Very helpful	Survivorship care visit checklist Extremely helpful

Other (please specify)

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* 10. To what extent are you familiar with the following community resources that support survivorship initiatives?

	Not at all familiar	Somewhat familiar	Moderately familiar	Very familiar	Completely familiar
Cancer survivor support group	Cancer survivor support group Not at all familiar	Cancer survivor support group Somewhat familiar	Cancer survivor support group Moderately familiar	Cancer survivor support group Very familiar	Cancer survivor support group Completely familiar
Tobacco cessation program	Tobacco cessation program Not at all familiar	Tobacco cessation program Somewhat familiar	Tobacco cessation program Moderately familiar	Tobacco cessation program Very familiar	Tobacco cessation program Completely familiar
CHW or patient navigators that help cancer survivors navigate	CHW or patient navigators that help cancer survivors navigate Not at all familiar	CHW or patient navigators that help cancer survivors navigate Somewhat familiar	CHW or patient navigators that help cancer survivors navigate Moderately familiar	CHW or patient navigators that help cancer survivors navigate Very familiar	CHW or patient navigators that help cancer survivors navigate Completely familiar
Nutrition and physical activity information for survivors	Nutrition and physical activity information for survivors Not at all familiar	Nutrition and physical activity information for survivors Somewhat familiar	Nutrition and physical activity information for survivors Moderately familiar	Nutrition and physical activity information for survivors Very familiar	Nutrition and physical activity information for survivors Completely familiar

Other (please specify)

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* 11. What do you think is needed the most to support cancer survivors in your community?

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* 12. Are EHR records being used to populate some of the data needed for cancer survivor care plans?

Yes

Other (please specify)

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* 13. If your clinic has a patient navigator: What type of training do you think your patient navigator(s) could benefit from?

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* 14. To what extent are you satisfied with the care that your patients with cancer receive?

Not at all satisfied

Slightly satisfied

Moderately satisfied

Very satisfied

Completely satisfied

Please explain why you chose the selection above.

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* 15. If you ordered NTCCP Cancer survivor kits; how many did you order, how many survivors received kits in your tribe, and how did you distribute them? Did you receive any feedback from the survivors?

Cancer Survivorship Survey for Northwest Tribal Healthcare Providers and Cancer Prevention Advocates

Question Title

* 1. Where do you work?

Question Title

* 2. What is your professional title?

Question Title

* 3. What is your role in cancer prevention and control within your community/clinic?

Question Title

* 4. If a patient has an abnormal cancer screening result, what step do you usually take next?

Question Title

* 5. What cancer treatment center do you refer cancer patients to?

Question Title

* 6. What are the most common cancers that you see in your practice? Please select the top 3

Question Title

* 7. How do you receive information about the care a patient referred for cancer treatment receives? (select all that apply)

Question Title

* 8. How do you promote cancer screenings in your clinic? (select all that apply)

Question Title

* 9. Please rank the resources our program can provide for increasing cancer screening in your patients from most helpful to least helpful

Question Title

* 10. To what extent are you familiar with the following community resources that support survivorship initiatives?

Question Title

* 11. What do you think is needed the most to support cancer survivors in your community?

Question Title

* 12. Are EHR records being used to populate some of the data needed for cancer survivor care plans?

Question Title

* 13. If your clinic has a patient navigator: What type of training do you think your patient navigator(s) could benefit from?

Question Title

* 14. To what extent are you satisfied with the care that your patients with cancer receive?

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* 15. If you ordered NTCCP Cancer survivor kits; how many did you order, how many survivors received kits in your tribe, and how did you distribute them? Did you receive any feedback from the survivors?

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* 16. Please feel free to provide additional information here: