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Online Eligibility Screening Questionnaire

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Thank you for your interest in the

Adolescent and Young Adult (AYA) Cancer Study!

What is the AYA Cancer Study?

Researchers at OHSU and OCHIN want to learn more about the experience of adolescent and young adult cancer survivors and to elevate the voices of survivors whose stories may not otherwise be heard.

We will use the results to create resources and educational materials that will help patients and their caregivers, shared via our public website: https://www.healthexperiencesusa.org/.

This study is led by Dr. Erika Cottrell (Principal Investigator) and funded by the National Center for Advancing Translational Science.

You can learn more about this study here.

What do I have to do?

If you are interested in participating in the study and sharing your experience, you will first need to complete the questionnaire below.

If enrolled in the study, you will be asked to complete a two-hour interview remotely via a secure platform (WebEx). Interviews will be videotaped and/or audiotaped with your consent. Interview questions will focus on your experience of cancer diagnosis, treatment, and survivorship.

You will receive a $50 gift card for your time.

Who is eligible?

This study might be a good fit for you if you:

Were diagnosed with cancer between the ages of 15-39
Are currently 1-3 years post-treatment

What if I have questions?

For any questions, please contact Vivian Christensen, Ph.D., at healthexperiences@ohsu.edu.

You can also learn more at www.healthexperiencesusa.org.

Participant ID

First Name

* must provide value

Last Name

* must provide value

Email Address

* must provide value

Phone Number

* must provide value

City

* must provide value

State

* must provide value

Please select the option that best describes your geographic location:

* must provide value

Frontier

Rural

Suburban

Urban

I prefer not to answer

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Gender Identity and Personal Pronouns

* must provide value

Date of Birth

* must provide value

M-D-Y

Race and Ethnicity

* must provide value

Asian

Black/African

Caucasian

Hispanic or Latin(a/o/x)

Native American

Pacific Islander

Other (please describe below)

Prefer not to answer

If "Other," please list here:

What is the highest degree or level of school you have completed?

* must provide value

What was your cancer diagnosis?

* must provide value

Brain or other Central Nervous System Tumors

Breast

Cervical

Colorectal

Leukemia

Lymphoma

Melanoma

Bone Sarcoma

Soft Tissue Sarcoma

Testicular

Thyroid

Other (please describe below)

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If other, please describe:

How old were you at the time of your diagnosis?

* must provide value

Did you receive treatment for your cancer?

* must provide value

Yes

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What type of treatment(s) did you receive for your cancer?

* must provide value

Chemotherapy

Radiation

Immunotherapy

Stem cell/bone marrow transplant

Surgery

Other (please describe below)

Other Treatment Type:

Are you currently undergoing treatment?

* must provide value

Yes No

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When did your treatment end?

* must provide value

Less than 1 year ago

1-3 years ago

4-5 years ago

Greater than 5 years ago

Did not receive treatment

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What insurance did you have during the course of your treatment (check all that apply)?

* must provide value

Private Insurance

Medicaid

Medicare

No insurance

Did not receive treatment

Other (please describe below)

I prefer not to answer

Other Insurance:

Please select your preferred method of contact (check all that apply):

Phone

If we reach a voicemail, is it okay to leave a detailed message?

Yes

N/A

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Is there a time of day that is best to reach you (check all that apply)?

Morning

Afternoon

Evening

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Morning

Afternoon

Evening

How did you find out about this study?

Letter from doctor

Conversation with doctor during appointment

Friend/family member

Flyer/advertisement

Social media

Referred by organization/community group

Other

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Specify

If you said social media, through which platform did you find out about the study?

* must provide value

Facebook

Twitter

Instagram

Snapchat

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If you said other, please describe:

Can we contact you about opportunities to participate in future research?

* must provide value

Yes No

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.