KAM II - OncoLink Survey

1. Survey: Exercise for the Person with Cancer

 
This information is part of a process called “informed consent” to allow you to understand this study before deciding whether to take part.


The purpose of this research survey is to help understand if on-line information about exercise helps to change exercise habits in the person with cancer.

The information collected in this survey is confidential and the researchers will not be able to identify who is filling out the information. In the report of this study, the respondents (you) will not be recognizable and all personal health information will be protected.

This survey is for adults, 18 years of age or older, who have a diagnosis of cancer.


This study is being conducted by a researcher named Lora Packel, who is a doctoral student at Walden University and a consultant for OncoLink.


If you agree to be in this study, you will be asked to:
□ Fill out the following brief survey on exercise after reading the exercise information contained on the OncoLink website.


Your participation in this study is voluntary. This means that everyone will respect your decision of whether or not you want to be in the study. No one at Walden University or OncoLink will treat you differently if you decide not to be in the study. If you decide to join the study now, you can still change your mind during the study. If you feel stressed during the study you may stop at any time. You may skip any questions that you feel are too personal.


The benefits of this study include generating information to better help health professionals understand exercise habits in the person with cancer. There is a small risk of feeling uncomfortable about answering questions about exercise, but you may skip any questions you feel are too personal.

Compensation:
None.


Contacts and Questions:
You may contact the researcher, Lora Packel at 215. 596.8678 or at lora.packel@waldenu.edu. If you want to talk privately about your rights as a participant, you can call Dr. Leilani Endicott. She is the Walden University representative who can discuss this with you. Her phone number is 1-800-925-3368, extension 1210. Walden University’s approval number for this study is 04-08-09-0375159 and it expires on April 7, 2010.


Statement of Consent:

I have read the above information and I feel I understand the study well enough to make a decision about my involvement.

Completion of the following survey indicates my consent to participate.

In this survey, exercise means that you sweat while doing an activity.
1. What is your age?
2. What type of cancer do you have?
3. Are you a male or female?
4. What is your race?
5. What is the highest educational level you achieved?
6. Where do you live?
7. What type of treatment have you gotten for your cancer?

Please check all types that you have gotten.
8. What was the stage of your cancer when you were first diagnosed?
9. How long ago did your cancer treatment end?

Do not count hormonal therapy.
10. In the last week, how much have you exercised?

Exercise means you sweat during an activity.
11. After reading the exercise information on this website, how likely are you to start an exercise program in the next 6 months?
12. After reading the exercise information on this website, how likely are you to Continue with your exercise program during treatment for cancer?
13. After reading the exercise information on this website, how likely are you to continue with your exercise program after treatment has stopped?
14. After reading the exercise information on this website, how likely are you to Increase the amount of exercise you do?
15. After reading the exercise information on this website, how likely are you to Decrease the amount of exercise you do?
16. After reading the exercise information on this website, how likely are you to stop exercising during my treatment for cancer?
17. After reading the exercise information on this website, I plan to stop or decrease my exercise because:

CLICK ALL THAT APPLY
18. After reading the exercise information on this website, I plan to start an exercise program or continue to exercise because:

CLICK ALL THAT APPLY
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