Diagnosed Health Conditions Question Title * 1. MURRAY HILL CENTER A NATIONAL MARKET RESEARCH COMPANY HAS BEEN COMMISSIONED TO INTERVIEW PARTICIPANTS FOR AN UPCOMING PROJECT. THIS WILL BE A 75 MIN LONG TELEPHONE INTERVIEW for specific type of cancer patients and / or their caregivers. IF YOU ARE INTERESTED IN THE PAID (100.00) PLEASE ANSWER ALL OF THE QUESTIONS. IF YOU QUALIFY FOR THE PROJECT, YOU WILL BE CONTACTED BY ONE OF OUR REPS Name: Company: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Country: Email Address: Phone Number: Question Title * 2. What is your gender Male Female Question Title * 3. What is your age Question Title * 4. Which of the following conditions have you OR someone you care for been diagnosed with? SELF LOVED ONE NONE Bladder cancer Bladder cancer SELF Bladder cancer LOVED ONE Bladder cancer NONE Breast cancer Breast cancer SELF Breast cancer LOVED ONE Breast cancer NONE Colon cancer Colon cancer SELF Colon cancer LOVED ONE Colon cancer NONE Head and neck cancer Head and neck cancer SELF Head and neck cancer LOVED ONE Head and neck cancer NONE Lung cancer Lung cancer SELF Lung cancer LOVED ONE Lung cancer NONE Lymphoma Lymphoma SELF Lymphoma LOVED ONE Lymphoma NONE Melanoma Melanoma SELF Melanoma LOVED ONE Melanoma NONE Ovarian cancer Ovarian cancer SELF Ovarian cancer LOVED ONE Ovarian cancer NONE Prostate cancer Prostate cancer SELF Prostate cancer LOVED ONE Prostate cancer NONE Other type of cancer Other type of cancer SELF Other type of cancer LOVED ONE Other type of cancer NONE Question Title * 5. What was the date when you (or your loved one) told that you have bladder cancer? Question Title * 6. How would you describe the current stage/spread of your (your loved ones) bladder cancer? Please choose one, your doctor has likely mentioned one of the terms below My cancer is localized. It is only in the bladder and has not grown into the surrounding muscle (i.e., non-muscle-invasive or low-grade bladder cancer). It has not spread to nearby lymph nodes or to other parts of the body. My cancer is locally advanced. It has grown into the surrounding muscle (i.e., muscle-invasive or high-grade bladder cancer), but has not spread to nearby lymph nodes or to other parts of the body. My cancer is recurrent. My cancer has returned after treatment and after a period of time during which the cancer was not detected. The same cancer came back in the location where it first started or somewhere else in my body. My cancer is metastatic. It has spread/metastasized to other parts of the body such as lung, liver, bones, bone marrow, skin Question Title * 7. What treatments, if any, have you EVER TAKEN (your loved one has taken for their) bladder cancer? DO NOT include any treatments you are on currently. No previous treatment Chemotherapy Radiation Surgery Clinical trial Other Question Title * 8. What treatments are you CURRENTLY TAKING (your loved one currently taking for their) bladder cancer? Chemotherapy Radiation Surgery Clinical trial Other Question Title * 9. When was your / your loved one's last treatment (surgery or radiation or chemotherapy/drug treatment)? Please provide a month and year Question Title * 10. Do you have access to a working webcam (i.e., a camera attached to your computer that can transmit a live video of you over the Internet)? Yes No Question Title * 11. You will need to have access to a computer with high speed internet during the interview. Do you have access to broadband (high speed internet)? Yes No Question Title * 12. This research will (also) involve use of web-conferencing software, which may require you to download a cookie in advance of the interview. This will enable you to view materials being shared by the moderator. Our web-conferencing software can occasionally be blocked by corporate firewalls and online security systems. To avoid this issue, would it be possible for you to participate using a personal computer (outside of work)? Please note that iPads, iPhones and tablets are typically not compatible with our software.Are you able to participate in the discussion on this basis? Yes No Question Title * 13. As part of participating in our study, we would like to also complete some written tasks over the course of a week regarding your experiences living with bladder cancer, including jotting down some key dates with regards to your diagnosis and treatment. The person who is going to interview you will call to explain these tasks before the interview.Would you be able to complete these tasks ahead of your interview? Yes No Question Title * 14. Would you prefer to complete the homework electronically (by typing in the answers on your computer) or using a pen and paper version? Electronic Pen and paper Done
