The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

Fertility changes due to cancer: an investigation of meaning, psychological distress, and psychological support needs of young women with breast cancer

Online Eligibility Screening Form

Thank you for your interest in this study.

Before you move on to the Consent form, it would be necessary to confirm that you are eligible to participate in the study. Below, you will be asked some basic questions about your eligibility to enroll in the study. It should take about 2 minutes to go through these questions.

Some of the questions may make you uncomfortable; you do not have to answer any question that you would not like to answer, but without answers to these questions, you will not be eligible to participate in the study. Your responses will not be recorded with any identifiable information, such as your name, until after you are enrolled in the study.

At that time, any of your identifiable information will be kept secure. If you do not enroll in this study, we will keep the information we collect during this pre-screening but there will be no way for anyone to link that information to you.

If you have any questions or concerns, please contact the Ethics Board that oversees this research.

COMIRB, (303) 724-1055.

Yes

I am between the ages of 18-45 years old

reset

I have a valid and private email account and access to the internet

reset

I can read and write in English

reset

My cancer diagnosis impacted my thoughts or feelings related to my fertility, reproductive plans, or parenting

reset

I am willing to comply with all study procedures and be available for the duration of the study (up to six months)

reset

You may be eligible to participate in future studies related to this topic conducted by the Psycho-Oncology Research Lab. Would you be interested in being contacted about participating in future studies?

Yes

reset

Please provide your email address so we can take you off our mailing list.

First name

Last name

Email Address

Phone number

How did you hear about this study?

Please explain

Congratulations! You are eligible to participate in this study! Please read the following consent form:

Study Title: Fertility changes due to cancer: an investigation of meaning, psychological distress, and psychological support needs of young women with breast cancer

Principal Investigator: Elissa Kolva, PhD

COMIRB No. 19-1812

Version Date: 3/10/2020

You are being asked to be in this research study because you have been diagnosed with breast cancer in the past 2 years.

If you join the study, you will be asked to provide information regarding your:

Diagnosis information

Reproductive concerns after cancer

Mood

Also, in order to collect detailed information about your treatment response, we would like to access your medical record for data such as:

Diagnosis

Treatment

Follow-up care

How often and when you returned for appointments

Notes from your provider regarding the care you were/are provided

Other diagnoses you might have subsequently

This study is trying to better understand the relationship between breast cancer, reproductive concerns, and psychological functioning.

This survey will take approximately 30 minutes to complete.
After you have completed the survey our study team will coordinate the delivery of a $15 electronic gift card to your email address.

At the end of this survey, you will also have the opportunity to refer your partner via email referral to complete a version of the survey and also receive a $15 electronic gift card.

Possible discomforts or risks include loss of confidentiality. There is a risk that people outside of the research team will see your research information. We will do all that we can to protect your information, but it can not be guaranteed. There may be risks the researchers have not thought of.

Every effort will be made to protect your privacy and confidentiality by storing records in a locked file cabinet, and utilizing electronic data sources which are password-protected and only available to study personnel.

The data we collect will be used for this study but may also be important for future research. Your data may be used for future research or distributed to other researchers for future study without additional consent if information that identifies you is removed from the data.

If you have questions, you can email Elissa Kolva, PhD, elissa.kolva@cuanschutz.edu You can email and ask questions at any time.

You may have questions about your rights as someone in this study. If you have questions, you can call the COMIRB ( the responsible Institutional Review Board). Their number is (303) 724-1055.

Reasons for not consenting

Please explain

Expand

First name

* must provide value

Last Name

* must provide value

Phone Number

* must provide value

Email address

* must provide value

Which of the following choices would you prefer:

Complete the survey online right now

Have a study team member contact you to continue the survey later

Send an email link to complete survey at another time

reset

Preferred method of contact

Phone

Either phone or email

Other

reset

Preferred method of contact?

You can also contact our team at: 720-848-8090 or oncpsych@ucdenver.edu

Thank you for completing this survey.

Unfortunately, you are not eligible to participate in this study. If you feel this is incorrect or if you have any other questions/concerns, please contact our research staff:

Alaina Carr & Sydneyjane Roberts
oncpsych@ucdenver.edu
720-848-8090

For information about available mental health supports for patients with cancer please click here [link to Resource sheet].

Thank you and have a wonderful day!

Link to download resource sheet

Attachment:resource sheet.PNG

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.