Date and time assigned
Leave blank, wait for Coordinator to do it
Now M-D-Y H:M
Assigned Interviewer:Leave blank, wait for Coordinator to do it
Aaliyah Liburd Angelicka Delgado Colleen Wilson Diana Claxton Jacqueline Francis Jenalis Hernandez Dr LaVerne Ragster Lenulisy Rosado Mallak Azzam Nachalie Ramos Nacheka Michel Na'Kia Armstrong Dr Noreen Michael Paola Rodriguez Trevesia Queeley Veronica Morales Yadriel Ortiz Yanellis Guilfuchi Participant Duplicate No Eligible Other
Interviewer filling out the application form:
Aaliyah Liburd Angelicka Delgado Colleen Wilson Diana Claxton Jacqueline Francis Jenalis Hernandez Dr LaVerne Ragster Lenulisy Rosado Mallak Azzam Nachalie Ramos Nacheka Michel Na'Kia Armstrong Dr Noreen Michael Paola Rodriguez Trevesia Queeley Veronica Morales Yadriel Ortiz Yanellis Guilfuchi Participant Other
Yes
No
Participant's Language on Contact Form
Application form is filled out:
Verbal (by phone)
In-person
Online (link or QR code)
Application form by phone:
Participant called study phone number
A previous study (database)
A previous study (database)
Alliance
Other
Infusion Center (UPRCCC) Multidisciplinary (UPRCCC) Radiotherapy (UPRCCC) Oncologic Hospital Dr. Isaac Gonzalez Martinez (PR) San Juan Municipal Hospital (PR) Caribbean Hematology & Oncology Center (St. Thomas) East End Medical Center (St. Thomas) St. Thomas Cancer Specialists (St. Thomas) VI Urologic Center (St. Thomas) Caribbean Hematology & Oncology Center (St. Croix) St. Croix Cancer Specialists (St. Croix) VI Urologic Center (St. Croix) Frederiksted Health Care, Inc. (St. Croix) Other location
Example: VI Department of Health
Thank you for your interest in our study!
The purpose of the study is to understand how extreme weather events and environmental hazards impact the continuum of cancer care (diagnosis and treatment) and quality of life in cancer survivors in Puerto Rico (PR) and the U.S. Virgin Islands (USVI).
This study is led by investigators from the University of Puerto Rico Comprehensive Cancer Center, the University of Puerto Rico Medical Sciences Campus, and the University of the Virgin Islands, and funded by the National Institutes of Health (Award #1P20CA294096-01).
Participation in this study requires the completion of an in-person or phone interview. The approximate duration of the interview will be 45 minutes. Participants will receive an incentive as compensation for their time.
If you are eligible, a member of the research team will be calling you in the next few weeks to confirm your eligibility and schedule an appointment to participate in the interview.
If you are interested in participating in our study, please provide the following information.
Now D-M-Y H:M
U.S. Virgin Islands (USVI) Puerto Rico (PR)
Interested in participating?
Yes
No
Reasons for not participating
I don't have time
I did not feel comfortable answering personal questions
Interview exceeded a reasonable time
It does not apply to me because I have not experienced extreme weather events
Other
A.1 Are you 21 years of age or older?
* must provide value
Yes No
A.2 Have you been diagnosed with cancer?
* must provide value
Yes No
A.3 Are you currently receiving cancer treatment or have you received active treatment within the last 12 months? Cancer treatment includes surgery, chemotherapy (oral or IV), immunotherapy, radiation, or medication to prevent or treat cancer (e.g., tamoxifen).
* must provide value
Yes No
A.4 Where do you currently live?
* must provide value
Puerto Rico
U.S. Virgin Islands
Other (in US or outside US)
A.4a Municipality (for PR)
Adjuntas Aguada Aguadilla Aguas Buenas Aibonito Arecibo Arroyo Añasco Barceloneta Barranquitas Bayamón Cabo Rojo Caguas Camuy Canóvanas Carolina Cataño Cayey Ceiba Ciales Cidra Coamo Comerío Corozal Culebra Dorado Fajardo Florida Guayama Guayanilla Guaynabo Gurabo Guánica Hatillo Hormigueros Humacao Isabela Jayuya Juana Díaz Juncos Lajas Lares Las Marías Las Piedras Loiza Luquillo Manatí Maricao Maunabo Mayagüez Moca Morovis Naguabo Naranjito Orocovis Patillas Peñuelas Ponce Quebradillas Rincón Río Grande Sabana Grande Salinas San Germán San Juan San Lorenzo San Sebastián Santa Isabel Toa Alta Toa Baja Trujillo Alto Utuado Vega Alta Vega Baja Vieques Villalba Yabucoa Yauco
St. Croix St. John St. Thomas
A.4ba St. Croix, if known, specify subdistrict:
Anna's Hope Village Christiansted East End Frederiksted Northcentral Northwest Sion Farm Southcentral Southwest Island subdivision not defined
A.4bb St. John, if known, specify subdistrict:
Central Coral Bay Cruz Bay East End Island subdivision not defined
A.4bc St. Thomas, if known, specify subdistrict:
Charlotte Amalie East End Northside Southside Tutu Water Island West End Island subdivision not defined
A.5 How did you learn about the study?
Through promotion in the waiting room (e.g. Flyer, Brochure, Poster)
A research staff told me about the study in a waiting room
Through promotion on social media (e.g. Facebook, Instagram, LinkedIn, YouTube)
Through promotion on regular media (e.g. Radio, TV, Newspaper)
A health professional told me about the study (e.g., Doctor, Nurse)
A family member, friend, or relative told me about the study
At a community activity
A previous study (database)
Other, please specify:
Don't know/Not sure
Refused to answer
A previous study (database)
Alliance
All of Us
Other
4.5a Please specify how you learned about the study.
Thank you for your interest in our research study! Based on your answers, you are ELIGIBLE to participate in the study.
A member of our research team will be calling you, in the next few weeks, to continue with next steps. The next steps will be to discuss informed consent and conduct an interview of approximately 45 minutes.
Please proceed to complete the following information.
Thank you for your interest in our research study! According to your answers, you are NOT ELIGIBLE to participate in the study. We thank you for your time.
Example: John
Last Name(s)
* must provide value
Example: Smith
Phone number
* must provide value
Example: (340) 555-5555
Example: (787) 444-4444
Example: insertnamehere@gmail.com
Prefered time to receive a phone call from our research team
* must provide value
May we send you a regular text message or WhatsApp message in case we are unable to reach you by phone?
* must provide value
Yes No
Participant's Final Status:Description:
This variable captures the final participant status for all individuals entered into the recruitment and study protocol. Every participant's record must be assigned a final status . Final participant statuses include:
Completed Questionnaire: Participant completed consent procedures and the full questionnaire.
No Contact: No response after ≥5 call attempts; email also attempted (if available) with no reply. Person chose not to participate: The individual chose not to participate in the study. Disconnected Number: The provided phone number has been disconnected after 2 calls on different days. Wrong Number: The provided phone number is incorrect, and no alternate number is available. Difficult Contact (Intermittent): Participant was reached at least once, but procedures could not be completed due to inconsistent responsiveness; includes ≥5 rescheduled or unanswered attempts, plus email if available. Consented-Difficult Contact: Participant completed consent but did not start the questionnaire; ≥5 follow‑up attempts were made, plus email if available. Incomplete Survey-Difficult Contact: Participant consented and started the questionnaire but did not complete it due to loss of contact. Non-Eligible: Participant does not meet eligibility criteria (e.g., Mini-Mental). Deceased: Participant passed away before completing the survey. Duplicate: The participant was identified as a duplicate record of an individual already registered in the study. Pilot Questionnaire: Participant completed consent procedures and the pilot version of the questionnaire as part of study testing.
Completed Questionnaire
No Contact (5 unanswered calls + email)
Person chose not to participate
Disconnected Number
Wrong Number
Difficult Contact (Intermittent)
Consented-Difficult Contact
Incomplete Survey-Difficult Contact
Non-Eligible
Deceased
Duplicate
Pilot Questionnaire
Other