appendix c treatment fidelity plan
strategies to enhance treatment fidelity

| Design of Study                                                   | Goal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              | Strategies for Implementation   |
|-------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------------------|
| Monitor treatment  dose for survivors  in PCI and UC  conditions. | Trained interventionists will follow manualized treatment  protocols for PCI and will complete quality assessment forms  following each session. Length of session and number of  attendees at each session will be tracked for all participants.  Trained study personnel will closely monitor use of any support  services by UC survivors and UC caregivers. We will also track  usage of any support services or programs through study  assessments.  Identify experienced bilingual and bi-cultural individuals who  can be trained as needed if one of the study interventionists  becomes unavailable. Additional training resources to be  provided by institutional support from GUMC as needed. This  plan will ensure adequate interventionist training and coverage. |                                 |
| Plan for  implementation  setbacks.                               |                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   |                                 |
| Monitoring and  Improving  Interventionist  Training              | Goal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              | Strategies for Implementation   |
| Standardize                                                       | Conduct training in-person at the same time. The 2-day training                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   |                                 |
| training.                                                         | session will include a study overview and mock sessions with  interventionists. GU PI and Co-Investigators and Site PIs will  observe and provide feedback of mock training sessions, with  input from co-investigators and consultants. Training will use  standardized training manuals for all research personnel.                                                                                                                                                                                                                                                                                                                                                                                                                                                             |                                 |
| Ensure  interventionist skill  acquisition.                       | Interventionists will complete two mock sessions during  training. Sessions will be scored for adherence according to an  a priori checklist. Intervention delivery checklists will be  reviewed by team investigators at weekly team meetings.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   |                                 |
| Minimize "drift" in  interventionists'  skills.                   | Conduct annual booster training sessions to review  interventionist identified problems and review protocol. Conduct  weekly meetings with research staff.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        |                                 |
| Accommodate team  members'  differences.                          | Evaluate effectiveness of assessment interviews of research  assistants via periodic monitoring of telephone interviews.  Provide intensive training to all study personnel according to  needs, background, or clinical experience. Review  interventionist experiences in team meetings and address as  needed.                                                                                                                                                                                                                                                                                                                                                                                                                                                                 |                                 |
| PCORI Research Plan                                               | 56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                |                                 |  
| PRINCIPAL INVESTIGATOR (LAST, FIRST, MIDDLE): Graves, Kristi, Dove Monitoring and  Improving Delivery  of Treatment Goal   | Strategies for Implementation                                                                                                                                                                                                                                                                                                                                                                                             |                                                                    |
|----------------------------------------------------------------------------------------------------------------------------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------|
| Control for  interventionists'  differences.                                                                               | Assess participants' perceptions of interventionists' warmth and  credibility via self-report satisfaction questionnaire and provide  feedback to interventionists. Include in analyses if appropriate.  Monitor participant complaints. Have different co-investigators  evaluate session notes and intervention delivery checklists.                                                                                    |                                                                    |
| Reduce differences                                                                                                         | Use treatment manual and handouts for PCI condition.                                                                                                                                                                                                                                                                                                                                                                      |                                                                    |
| within treatment. Ensure adherence  to treatment  protocol.                                                                | Interventionists will complete a checklist of intervention  components delivered after each session for all groups. Emphasize in training sessions the rationale for keeping  conditions separate. As survivors and caregivers in the UC  condition are not exposed to in any way to manualized group  sessions, contamination concerns are lessened. We will track  usage of other support programs by all participants. |                                                                    |
| Monitoring and                                                                                                             |                                                                                                                                                                                                                                                                                                                                                                                                                           |                                                                    |
| Improving Receipt                                                                                                          | Goal                                                                                                                                                                                                                                                                                                                                                                                                                      | Strategies for Implementation                                      |
| of Treatment                                                                                                               | Minimize  contamination  between conditions. Ensure participant                                                                                                                                                                                                                                                                                                                                                           | Assess skills and functioning at baseline (e.g., self-efficacy for |
| comprehension.                                                                                                             | communication, social support, distress). Intervention includes  the practice of skills and behavioral strategies within each  group session. Have interventionist ask questions/use prompts  that ask participants to paraphrase/summarize content. Record  interventionists' perceptions of participant understanding after  each session.                                                                              |                                                                    |
| Maximize  participant ability to  use skills.                                                                              | Measure mediating variables immediately post-intervention and  6-months post intervention. Ask participants to provide  feedback on their ability to understand and use materials.                                                                                                                                                                                                                                        |                                                                    |
| Monitoring and  Improving  Enactment of  Treatment Skills                                                                  | Goal                                                                                                                                                                                                                                                                                                                                                                                                                      | Strategies for Implementation                                      |
| Ensure participant  ability to perform  behavioral skills.                                                                 | Monitor homework completion and engagement in session  discussion.                                                                                                                                                                                                                                                                                                                                                        |                                                                    |  
Strategies adapted from recommendations provided in Bellg AJ, Borrelli B, Resnick B, Hecht J, Minicucci DS, Ory M, Ogedegbe G, Orwig D, Ernst D, Czajkowski S, et al. Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH Behavior Change Consortium. *Health* Psychol 2004;23(5):443-451. PMID:15367063.
appendix c treatment fidelity plan
appendix d draft baseline interview

INSTRUCTIONS READ BY RESEARCH ASSISTANT: This questionnaire is for Latina Breast Cancer survivors and their caregivers. Remember that you can skip any question you do not want to answer. We will not have your name or information with your responses. There are no right or wrong answers. Thank you.
appendix c treatment fidelity plan
section a breast cancer medical

When you were diagnosed with breast cancer, and where did you live at the time of diagnosis?  
Date _______/ _______ State and Country ______________
Month / Year  
How old were you when you were diagnosed? ________ years  
Please choose one response, indicating, Yes or No.  
| Please choose one response, indicating, Yes or No.                                                                                                                                                                               |                                                                          |                                   |                   |     |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------------------------------------------------------------------|-----------------------------------|-------------------|-----|
| Was your cancer bilateral (in both breasts)?                                                                                                                                                                                     | Yes                                                                      | No                                | Unsure            | N/A |
| Do you remember the grade or stage of your cancer when it was diagnosed?   (Grade 0, 1, 2, 3, 4 / Stage 0, I, II, III, IV)  If Yes, what grade or stage was the cancer at the time of  diagnosis ?_______                        | Yes                                                                      | No                                | Unsure            | N/A |
| Did your cancer spread to your lymph nodes?                                                                                                                                                                                      | Yes                                                                      | No                                | Unsure            | N/A |
| Do you remember the size of your tumor?                                                                                                                                                                                          | Yes                                                                      | No                                | Unsure            | N/A |
|                                                                                                                                                                                                                                  | If Yes, what was the size of your tumor? ____                            |                                   |                   |     |
| Have you ever been diagnosed with breast cancer a second time?                                                                                                                                                                   | Yes                                                                      | No                                | Unsure            | N/A |
|                                                                                                                                                                                                                                  | If Yes, how old were you at your 2nd diagnosis? _____ years              |                                   |                   |     |
|                                                                                                                                                                                                                                  | Was this a recurrence of the original cancer or a new primary diagnosis? |                                   |                   |     |
|                                                                                                                                                                                                                                  | ______ Recurrence                                                        | _____ New Primary                 | ______ Don't know |     |
| Have you had any other type of cancer? If Yes, please specify:                                                                                                                                                                   | Yes                                                                      | No                                | Unsure            | N/A |
| _______________ Did you have radiation therapy for your breast cancer?                                                                                                                                                           | Yes                                                                      | No                                | Unsure            | N/A |
| Are you still receiving radiotherapy?                                                                                                                                                                                            | Yes                                                                      | No                                | Unsure            | N/A |
| Did you have chemotherapy for your breast cancer?                                                                                                                                                                                | Yes                                                                      | No                                | Unsure            | N/A |
| Are you still receiving chemotherapy?                                                                                                                                                                                            | Yes                                                                      | No                                | Unsure            | N/A |
| Did you take any hormone treatment for your breast cancer   (For example, Tamoxifen, Femara, Arimidex or Aromasin)?   If Yes, for how long? __________ (months / years)    If Yes, are you currently taking a hormone? _____ Yes | ____ No                                                                  |                                   |                   |     |
|                                                                                                                                                                                                                                  | Which one? ____________                                                  | For how long? ___________ (months |                   |     |
| / years)                                                                                                                                                                                                                         | Yes                                                                      | No                                | Unsure            | N/A |
| PCORI Research Plan                                                                                                                                                                                                              | 58                                                                       |                                   |                   |     |  
| PRINCIPAL INVESTIGATOR (LAST, FIRST, MIDDLE): Graves, Kristi, Dove Had you had surgery to treat your breast cancer?  Which type of surgery have you had? _____ Mastectomy _____ Bilateral Mastectomy _____ Lumpectomy  Have you had reconstruction or plastic surgery?  If Yes, what type of reconstruction?  _____ Breast implants  _____ Removed tissue from other part of your body (eg. tram flap) ______Other (Specify): _________________________________ Had you gone through menopause ("the change of life") before your diagnosis?   | Yes   | No   | Unsure   | N/A   |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------|------|----------|-------|
| Is mammography a source of stress for you?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     | Yes   | No   | Unsure   | N/A   |
| Are your regular appointments for your follow up a source of stress?                                                                                                                                                                                                                                                                                                                                                                                                                                                                           | Yes   | No   | Unsure   | N/A   |
| Do your regular appointments for your follow up interfere with your usual daily  activities? Do you experience side effects from your breast cancer treatment that interfere  with your regular daily activities? Has your doctor made any specific recommendations regarding foods to eat?                                                                                                                                                                                                                                                    | Yes   | No   | Unsure   | N/A   |
| Has your doctor made any specific recommendations on exercising?                                                                                                                                                                                                                                                                                                                                                                                                                                                                               | Yes   | No   | Unsure   | N/A   |  
Yes No Unsure N/A Yes No Unsure N/A
appendix c treatment fidelity plan
section b medical history -

The next group of questions is about your medical history. I will read the list to you. Please indicate whether you have these problems, indicating yes or no as I read each one.  
| Yes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         | No   | Unsure   |
|-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------|----------|
| Arthritis (rheumatoid and osteoarthritis) Osteoporosis Asthma Chronic obstructive pulmonary disease (COPD), acquired respiratory distress syndrome  (ARDS) or emphysema Angina Congestive heart failure (or heart disease) Heart attack (myocardial infarct) Neurological disease (such as multiple sclerosis or Parkinson's) Stroke or TIA Peripheral vascular disease Diabetes—types I and II Upper gastrointestinal disease (ulcer, hernia, reflux) Depression Anxiety or panic disorders Visual impairment (i.e. cataracts, glaucoma, macular degeneration) Hearing impairment (very hard of hearing, even with hearing aids) Degenerative disc disease (back disease, spinal stenosis or severe chronic back pain) Obesity and/or body mass index > 30 |      |          |  
SECTION C: ACCULTURATION - Survivors and Caregivers We would like to ask you some questions about languages you speak. Please choose one response. I will read the question and then the answer choices.  
| Only                                                                                              | More Spanish   | Both    | More English   | Only    | Other?   |    |
|---------------------------------------------------------------------------------------------------|----------------|---------|----------------|---------|----------|----|
| Spanish                                                                                           | than English   | Equally | than Spanish   | English |          |    |
| In general, what language(s) do                                                                   | 1              | 2       | 3              | 4       | 5        | 6  |
| you read and speak? What was the language(s) you                                                  | 1              | 2       | 3              | 4       | 5        | 6  |
| used as a child What language(s) do you usually                                                   | 1              | 2       | 3              | 4       | 5        | 6  |
| speak at home? In which language(s) do you                                                        | 1              | 2       | 3              | 4       | 5        | 6  |
| usually think? What language(s) do you usually                                                    | 1              | 2       | 3              | 4       | 5        | 6  |
| speak with your friends? In what language(s) are the T.V.  and Radio programs you usually  watch? | 1              | 2       | 3              | 4       | 5        | 6  |  
The next questions are about your friends. Please circle your answer.  
| All                                                                     | More Latinos    |                     |                               |     |        |    |
|-------------------------------------------------------------------------|-----------------|---------------------|-------------------------------|-----|--------|----|
| Latinos/Hispanics                                                       | than  Americans | About  Half &  Half | More  Americans  than Latinos | All | Other? |    |
| Americans                                                               |                 |                     |                               |     |        |    |
| Your closest friends are                                                | 1               | 2                   | 3                             | 4   | 5      | 6  |
| You prefer going to social  gatherings/parties at  which the people are | 1               | 2                   | 3                             | 4   | 5      | 6  |
| If you could choose your  children's friends you  would want them to be | 1               | 2                   | 3                             | 4   | 5      | 6  |
appendix c treatment fidelity plan
section d communication with providers--survivors

Please rate the next items about the visits with your health care provider where you talked about your breast cancer treatment and survivorship care plans. Please choose one answer for each item and answer every question. There is no right or wrong answer; just tell us how you feel.  
| How was your health care provider at…                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       | N/A   | Poor   | Fair   | Good   | Very Good   | Excellent   |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------|--------|--------|--------|-------------|-------------|
| Fully understanding your fears (telling you  that he/she really understands your fears;  not ignoring things) Showing care and kindness (being truly  interested; not being cold or uncaring) Being positive (having a positive way of  talking with you; a good attitude; being  honest but not negative about your illness) Telling you things clearly (fully  understanding your questions, tell you  things in a way you understand, giving you  good and helpful information) Helping you to take control (talking with  you about what you can do to make your  health better; being helpful and not  scolding you) Making a plan of action with you (talking  about the options; including you in making  choices as much as you want to be  included; not ignoring your thoughts and  feelings on things) Helping you feel calm (friendly and warm  to you, treating you with respect, not cold  or rushed) Letting you tell your story (letting you talk  about your illness or fears, not interrupting  you) Really listening (paying close attention to  you and what you were saying)  Being interested in you as a whole person  (asking/knowing important details about  your life and illness, you are not "just a  number") |       |        |        |        |             |             |
appendix c treatment fidelity plan
section e social support -

I will read a list of things that other people do for us or give us that may be helpful or supportive. Please listen to each statement carefully and indicate an answer that is closest to your situation. Answering "1" would mean that you get that type of support "much less than you would like" and answering "5" would mean that you get that type of support "as much as you would like." Answer each item as best as you can. There are no rights or wrong answers.  
| As much  as I  would  like                                                       |    |    |    |    |    |    |
|----------------------------------------------------------------------------------|----|----|----|----|----|----|
| Much less                                                                        |    |    |    |    |    |    |
| than I would like                                                                |    |    |    |    |    |    |
| I have people who care about what happens to me.                                 | 1  | 2  | 3  |    | 4  | 5  |
| I get love and affection.                                                        | 1  | 2  | 3  |    | 4  | 5  |
| I get chances to talk to someone about problems at  work or with my homework.    | 1  | 2  | 3  | 4  | 5  |    |
| I get chances to talk to someone I trust about my  personal and family problems. | 1  | 2  | 3  | 4  | 5  |    |
| I get chances to talk about money matters.                                       | 1  | 2  | 3  |    | 4  | 5  |
| I get invitations to go out and do things with other  people.                    | 1  | 2  | 3  | 4  | 5  |    |
| I get useful advice about important things in life.                              | 1  | 2  | 3  |    | 4  | 5  |
| I get help when I'm sick in bed.                                                 | 1  | 2  | 3  |    | 4  | 5  |
appendix c treatment fidelity plan
section f social constraints--survivors only

Sometimes, even when people have good intentions, they may say or do things that upset you. Think about the last two weeks and indicate how often the most important person in your life did the following things. Use the scale that ranges from: 1=Never, 2=Rarely, 3=Sometimes, 4=Often. Please circle only one response for each question.  
| Never                                                                                                                                                                              | Rarely   | Sometimes   | Often   |    |
|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------|-------------|---------|----|
| How often did you feel that you had to keep your feelings about your  breast cancer to yourself, because they made the most important                                              | 1        | 2           | 3       | 4  |
| person in your life feel uncomfortable?  How often when you talked about your breast cancer, did the most  important person in your life give you the idea that he/she didn't want | 1        | 2           | 3       | 4  |
| to hear about your cancer?  How often did the most important person in your life let you down by  not showing you as much love and concern as you would have liked?                | 1        | 2           | 3       | 4  |
| How often has the most important person in your life really got on  your nerves?                                                                                                   | 1        | 2           | 3       | 4  |  
In the previous questions can you tell me who did you rate as the most important person in your life?  
SECTION G: DYADIC COPING - Survivors and Caregivers  
| Sometimes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      | Often True   | Always True   |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------------|---------------|
| Never true                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     | Seldom true  | true          |
| My family member is willing to listen  to me when I just need to talk My family member gives me a great  deal of affection and warmth. My family member ignores or makes  light of my concerns. My family member supports me as I  try to cope with the illness. When around my family member, I  pretend things are going better than  they really are. My family member and I work as a  team to manage the effects of the  illness. My family member gives me positive  feedback for my attempts to cope  with the illness. |              |               |  
SECTION H: QUALITY OF LIFE (PROMIS) - Survivors and Caregivers NOTE: These are sample items. Computerized Adaptive Testing (CAT) will generate the specific items for each participant based on their prior answers. This approach allows for the most precise estimates.
appendix c treatment fidelity plan
global health

Please respond to each item by choosing only one answer for each question.  
| Completely                                                                                                                                                                                                                                                      | Mostly     | Moderately   | A Little   | Not at All   |              |    |    |    |    |    |
|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------|--------------|------------|--------------|--------------|----|----|----|----|----|
| To what extent are you able to carry  out your everyday physical activities  such as walking, climbing stairs,  carrying groceries, or moving a  chair? Please indicate how true each statement has been for you during the past 7 days. Never Rarely Sometimes | Often      | Always       |            |              |              |    |    |    |    |    |
| How often have you been bothered  by emotional problems such as  feeling anxious, depressed or  irritable?                                                                                                                                                      | None       | Mild         | Moderate   | Severe       | Very  Severe |    |    |    |    |    |
| How would you rate your fatigue on  average?                                                                                                                                                                                                                    | Worst      |              |            |              |              |    |    |    |    |    |
| imaginable  pain 10                                                                                                                                                                                                                                             |            |              |            |              |              |    |    |    |    |    |
| How would you rate your pain on  average?                                                                                                                                                                                                                       | No  pain 0 | 1            | 2          | 3            | 4            | 5  | 6  | 7  | 8  | 9  |  
| Social Health                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    | Excellent   | Very   | Good   | Fair   | Poor   |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-------------|--------|--------|--------|--------|
| Good                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             |             |        |        |        |        |
| In general, would you say your health is: In general, would you say your quality of life  is: In general, how would you rate your physical  health? In general, how would you rate your mental  health, including your mood and your ability  to think? In general, how would you rate your  satisfaction with your social activities and  relationships? In general, please rate how well you carry  out your usual social activities and roles.  (This includes activities at home, at work and  in your community and responsibilities as a  parent, child, spouse, employee, friends,  etc). |             |        |        |        |        |
appendix c treatment fidelity plan
physical health

The following questions ask about your ability to stand and move with and without support. "Support" means using items such as canes, walking sticks, walkers and leg braces, or other people.  
Can you walk 25 feet on a level surface (with or without support)? Yes No Yes Participant receives all items; NoParticipant skips to question "Are you able to wash and dry your body?  
| Never                                                                                                                                                                                                                                                                                                                                                                                                                                                                                | Rarely   | Sometimes   | Usually   | Always   |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|----------|-------------|-----------|----------|
| I have trouble doing all of my regular  leisure activities with others I have trouble doing all of the family  activities that I want to I have trouble doing all of my usual  work (include work at home) I have trouble doing all of the  activities with friends that I want to do I have to limit my regular activities  with friends I have to limit my regular family  activities I have trouble doing all of the work  that is really important to me (include  work at home) |          |             |           |          |
appendix c treatment fidelity plan
physical health continued

| Without any                                                                                                                                                                                                                                                                                                                                                   | With a little   | With some     | With much   | Unable to   |           |
|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------|---------------|-------------|-------------|-----------|
| difficulty                                                                                                                                                                                                                                                                                                                                                    | difficulty      | difficulty    | difficulty  | do          |           |
| Are you able to walk a block on flat  ground? Are you able to walk up and down  two steps? Are you able to run at a fast pace for  two miles? Are you able to do yard work like  raking leaves, weeding, or pushing a  lawn mower?                                                                                                                            | Not at all      | Very little   | Somewhat    | Quite a lot | Cannot do |
| Does your health now limit you in  doing strenuous activities such as  backpacking, skiing, playing tennis,  bicycling or jogging?                                                                                                                                                                                                                            | Without any     | With a little | With some   | With much   | Unable to |
| difficulty                                                                                                                                                                                                                                                                                                                                                    | difficulty      | difficulty    | difficulty  | do          |           |
| Are you able to wash and dry your  body? Are you able to get in and out of bed? Are you able to bend down and pick  up clothing from the floor? Are you able to push open a heavy  door? Are you able to reach and get down  an object (such as a can of soup)  from above your head? Does your health now limit you in  doing eight hours of physical labor? |                 |               |             |             |           |  
SECTION I: MENTAL HEALTH (BSI) - Survivors and Caregivers Now I am going to read a list of problems and complaints that people sometimes have. Please tell me how much discomfort that problem has caused you in the last two weeks. Your answer choices are not at all, slightly, moderately or extremely.  
|                                              | Not at All   | Slightly   | Moderately   | Extremely   |
|----------------------------------------------|--------------|------------|--------------|-------------|
| Nervousness or shakiness inside 1            | 2            | 3          | 4            |             |
| Suddenly scared for no reason 1              | 2            | 3          | 4            |             |
| Feeling lonely 1                             | 2            | 3          | 4            |             |
| Feeling fearful 1                            | 2            | 3          | 4            |             |
| Feeling blue 1                               | 2            | 3          | 4            |             |
| Feeling not interested in things 1           | 2            | 3          | 4            |             |
| Feeling tense or keyed up 1                  | 2            | 3          | 4            |             |
| Spells of terror or panic 1                  | 2            | 3          | 4            |             |
| Feeling hopeless about the future 1          | 2            | 3          | 4            |             |
| Feeling so restless you couldn't sit still 1 | 2            | 3          | 4            |             |
| Feeling of worthlessness 1                   | 2            | 3          | 4            |             |
appendix c treatment fidelity plan
section j cancer related distress

I'm going to read a list of comments made by some people who have cancer in their family. Please tell me how frequently these comments were true for you during the past seven days. **[READ STATEMENT]**
Would you say this occurred...not at all, rarely, sometimes, or often?  
Not Someat All Rarely **times Often**  
I thought about it when I didn't mean to............... 0..................1…….............3………...........5  
I avoided letting myself get upset when I thought about it or was reminded of it................................. 0..................1…….............3………...........5  
I had trouble falling asleep or staying sleep, because of pictures or thoughts about it that came into my mind 0..................1…….............3………...........5  
I had dreams about it............................................... 0..................1…….............3………...........5  
I stayed away from reminders of it........................ 0..................1…….............3………...........5  
I felt as if it hadn't happened or it wasn't real........ 0..................1…….............3………...........5 I tried not to talk about it...................................... 0..................1…….............3………...........5 Pictures about it popped into my mind................. 0..................1…….............3………...........5 Other things kept making me think about it......... 0..................1…….............3………...........5  
I was aware that I still had a lot of feelings about it, but I didn't deal with them....................... 0..................1…….............3………...........5 I tried not to think about it....................................... 0..................1…….............3………...........5  
Any reminder brought back feelings about it........ 0..................1…….............3………...........5 My feelings about it were kind of numb................ 0..................1…….............3………...........5  
I had tried to remove it from memory......................... 0..................1…….............3………...........5 I had waves of strong feelings about it.................. 0..................1…….............3………...........5
appendix c treatment fidelity plan
section k stigma scale--survivors only

The following questions pertain to your feelings about your breast or mastectomy site. Please indicate the way each statement pertains to you personally. When answering consider how you felt over the **past month**. Using the scale below we would like for you to answer on a scale of 1 to 5, where 1 is never and 5 is always. Please circle only one answer for each question.  
| S: I avoid looking at my scars from breast     | Never   | Almost   | Sometime   |
|------------------------------------------------|---------|----------|------------|
| surgery                                        | never   | s        |            |
| I feel less feminine since cancer              | Never   | Almost   | Sometime   |
| never                                          | s       |          |            |
| I avoid physical intimacy                      | Never   | Almost   | Sometime   |
| never                                          | s       |          |            |
| I feel part of me must remain hidden           | Never   | Almost   | Sometime   |
| never                                          | s       |          |            |
| I am afraid of touching the scars from breast  | Never   | Almost   | Sometime   |
| surgery                                        | never   | s        |            |
| I avoid close physical contact such as hugging | Never   | Almost   | Sometime   |
| never                                          | s       |          |            |
| I would keep my chest covered during sexual    | Never   | Almost   | Sometime   |
| intimacy                                       | never   | s        |            |
| I feel sexually attractive when I am nude      | Never   | Almost   | Sometime   |
| never                                          | s       |          |            |
appendix c treatment fidelity plan
section l medical experiences -

Thinking about the relationship between race or ethnicity and the American medical system in general - not just specific to the care you received during your breast cancer experiences—please rate how strongly you agree or disagree with the following statements. Your answer choices are: strongly disagree, disagree, neutral, agree, strongly agree, unsure, or prefer not to answer.  
| People of my ethnic group cannot trust                                                                                     | Prefer   |          |       |       |        |                |
|----------------------------------------------------------------------------------------------------------------------------|----------|----------|-------|-------|--------|----------------|
| doctors and health care workers                                                                                            | Strongly | Strongly |       |       |        |                |
| Disagree                                                                                                                   | Disagree | Neutral  | Agree | Agree | Unsure | not to  answer |
| Doctors and health care workers treat  people of my ethnic group like "guinea  pigs"                                       | Prefer   |          |       |       |        |                |
| Strongly                                                                                                                   | Strongly |          |       |       |        |                |
| Disagree                                                                                                                   | Disagree | Neutral  | Agree | Agree | Unsure | not to  answer |
| People of my ethnic group receive the  same medical care from doctors and health  care workers as people from other groups | Prefer   |          |       |       |        |                |
| Strongly                                                                                                                   | Strongly |          |       |       |        |                |
| Disagree                                                                                                                   | Disagree | Neutral  | Agree | Agree | Unsure | not to  answer |
| Doctors and health care workers do not  take the medical complaints of people of  my ethnic group seriously                | Prefer   |          |       |       |        |                |
| Strongly                                                                                                                   | Strongly |          |       |       |        |                |
| Disagree                                                                                                                   | Disagree | Neutral  | Agree | Agree | Unsure | not to  answer |
| I have personally been treated poorly or  unfairly by doctors or health care workers  because of my ethnicity              | Prefer   |          |       |       |        |                |
| Strongly                                                                                                                   | Strongly |          |       |       |        |                |
| Disagree                                                                                                                   | Disagree | Neutral  | Agree | Agree | Unsure | not to  answer |
| If you don't speak English fluently you will  not receive the same type of care that the  people who speaks English well   | Prefer   |          |       |       |        |                |
| Strongly                                                                                                                   | Strongly |          |       |       |        |                |
| Disagree                                                                                                                   | Disagree | Neutral  | Agree | Agree | Unsure | not to  answer |
appendix c treatment fidelity plan
section m medical care experiences

In this section, we list some more things people said about medical care. I'd like to remind you that all of your answers are confidential and there are no right or wrong answers to any questions. We are interested in your opinion. We are interested in how good or bad you feel about the overall medical care you have received from the doctor you see the most often. For caregivers: If you have not received care recently, think about what you would expect if you needed care today. Please indicate how strongly you agree or disagree with each of the following statements. Please choose only one response option for each question.  
| Doctors are good about explaining the reasons for           | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
|-------------------------------------------------------------|------------|------------|-------------|---------|------------|
| medical tests                                               | Disagree   | Agree      |             |         |            |
| I think my doctor's office has everything needed to         | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| provide complete medical care.                              | Disagree   | Agree      |             |         |            |
| The medical care I have been receiving is just about        | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| perfect.                                                    | Disagree   | Agree      |             |         |            |
| Sometimes doctors make me wonder if their diagnosis is      | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| correct.                                                    | Disagree   | Agree      |             |         |            |
| I feel confident that I can get the medical care I need     | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| without being set back financially.                         | Disagree   | Agree      |             |         |            |
| When I go for medical care, they are careful to check       | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| everything when treating and examining me.                  | Disagree   | Agree      |             |         |            |
| I have to pay for more of my medical care than I can        | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| afford.                                                     | Disagree   | Agree      |             |         |            |
| I have easy access to the medical specialists I need.       | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| Disagree                                                    | Agree      |            |             |         |            |
| Where I get medical care, people have to wait too long      | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| for emergency treatment.                                    | Disagree   | Agree      |             |         |            |
| Doctors act too businesslike and impersonal toward me.      | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| Disagree                                                    | Agree      |            |             |         |            |
| My doctors treat me in a very friendly and courteous        | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| manner.                                                     | Disagree   | Agree      |             |         |            |
| Those who provide my medical care sometimes hurry           | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| too much when they treat me.                                | Disagree   | Agree      |             |         |            |
| Doctors sometimes ignore what I tell them.                  | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| Disagree                                                    | Agree      |            |             |         |            |
| I find it hard to get an appointment for medical care right | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| away.                                                       | Disagree   | Agree      |             |         |            |
| I am dissatisfied with some things about the medical        | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| care I receive.                                             | Disagree   | Agree      |             |         |            |
| I am able to get medical care whenever I need it.           | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| Disagree                                                    | Agree      |            |             |         |            |
appendix c treatment fidelity plan
section n rcope - religion

Think about how you try to understand and deal with the worst problems in your life. Please listen to the items below and think about whether these statements apply to you. Please choose only one answer to indicate how often you have done these things to understand or deal with the worst problems in your life.  
| I thought about how my life is part of a large spiritual force          | Not at   | Somewhat   | Quite a   | A great   |
|-------------------------------------------------------------------------|----------|------------|-----------|-----------|
| all                                                                     | bit      | deal       |           |           |
| I worked together with God as partners to go through the difficult      | Not at   | Somewhat   | Quite a   | A great   |
| times                                                                   | all      | bit        | deal      |           |
| I looked to God for strength, support, and guidance                     | Not at   | Somewhat   | Quite a   | A great   |
| all                                                                     | bit      | deal       |           |           |
| I felt that the stressful situations are a way for God to punish me for | Not at   | Somewhat   | Quite a   | A great   |
| my sins or my lack of spirituality                                      | all      | bit        | deal      |           |
| I wondered whether God had abandoned me                                 | Not at   | Somewhat   | Quite a   | A great   |
| all                                                                     | bit      | deal       |           |           |
| I tried to make sense of the situation without relying on God           | Not at   | Somewhat   | Quite a   | A great   |
| all                                                                     | bit      | deal       |           |           |
| Until what point does your religion play a role in understanding and    | Not at   | Somewhat   | Quite a   | A great   |
| deal with the stressful situations?                                     | all      | bit        | deal      |           |
appendix c treatment fidelity plan
section o thinking beyond oneself

The next few questions are about your thoughts and opinions about learning about cancer and its impact. I will read you the question and then the answer choices.  
| Learning about cancer and its impact is important for                                                                                            | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
|--------------------------------------------------------------------------------------------------------------------------------------------------|------------|------------|-------------|---------|------------|
| both my spouse and I.                                                                                                                            | Disagree   | Agree      |             |         |            |
| Whether my [name of other person's role: spouse/  partner/ sister/ mom/daughter] learns about cancer  and its impact could affect my future too. | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| Disagree                                                                                                                                         | Agree      |            |             |         |            |
| If my [spouse/ partner/ sister/ mom/ daughter] plans to  learn about cancer and its impact, I would say that  is a good idea.                    | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| Disagree                                                                                                                                         | Agree      |            |             |         |            |
| I can think of reasons learning about cancer and its  impact is important to my [spouse/ partner/ sister/  mom/ daughter]                        | Strongly   | Disagree   | Uncertain   | Agree   | Strongly   |
| Disagree                                                                                                                                         | Agree      |            |             |         |            |
|                                                                                                                                                  |            |            |             |         |            |
appendix c treatment fidelity plan
section p communication self-efficacy--survivors and

The following questions ask about your communications with your caregiver. On a scale of 1 to 10, 1 meaning "not at all confident" and 9 meaning "totally confident", please tell me how confident you are that you can talk with your caregiver about the following things.  
| SURVIVORS: I am confident in my ability to…                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    | How confident are   | N/A   |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|---------------------|-------|
| you? 1 to 10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   |                     |       |
| Talk with my caregiver about my cancer Talk with my caregiver about changes in my body due to treatment Talk with my caregiver (if a spouse or partner) about our sexual  relationship Talk with my caregiver about my fears Talk with my caregiver about future appointments with my doctor Talk with my caregiver about getting a will or other end of life  documents Talk with other members of my family about my breast cancer Talk with my caregiver to ask for extra help or support CAREGIVERS: I am confident in my ability to…                                      | How confident are   | N/A   |
| you? 1 to 10                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   |                     |       |
| Talk with the survivor about her cancer Talk with the survivor caregiver about changes in her body due to  treatment Talk with the survivor (if a spouse or partner) about our sexual  relationship Talk with the survivor about my own fears Talk with the survivor about future appointments with her doctors Talk with the survivor about getting a will or other end of life  documents Talk with other members of my family about the survivor's breast  cancer Talk with other members of my family to ask for extra help or support  in providing care to the survivor. |                     |       |  
SECTION Q: CANCER BEHAVIOR INVENTORY (MERLUZZI)—Survivors NOTE: We will adapt the following items based on experiences of Nueva Vida and Dr. Nápoles in administering these items to Latina survivors The next questions are about things you might do when receiving treatment for cancer. On a scale of 1 to 9, 1 meaning "not at all confident" and 9 meaning "totally confident, please tell me how confident you are that you can accomplish each behavior.  
Not at all  
confident  
Moderately  
confident  
Totally  
confident  
Maintaining independence.  1 234  5 678  9  
Maintaining a positive attitude.  1 234  5 678  9  
Accepting that I have cancer.  1 234  5 678  9 Maintaining work activity.  1 234  5 678  9  
Asking nurses questions.  1 234  5 678  9  
Remaining relaxed throughout treatments and  
not allowing scary thoughts.  1 234  5 678  9  
Seeking support from people & groups  
outside the family.  1 234  5 678  9  
Maintaining a daily routine.  1 234  5 678  9  
Asking technologists questions.  1 234  5 678  9  
Using denial. (Putting things out of my mind  
at times)  1 234  5 678  9  
Remaining relaxed throughout treatment  
(chemotherapy, radiation).  1 234  5 678  9  
Coping with physical changes.  1 234  5 678  9  
Ignoring things that cannot be death with.  1 234  5 678  9  
Actively participating in treatment decisions.  1 234  5 678  9  
Sharing feelings of concern..  1 234  5 678  9  
Remaining relaxed while waiting at least one  
hour for my appointment.  1 234  5 678  9  
Expressing personal feelings of anger or  
hostility.  1 234  5 678  9  
Keeping busy with activities.  1 234  5 678  9  
Finding an escape ("getting away from it all"  
at times).  1 234  5 678  9  
Reducing any anxiety with getting my blood  
drawn.  1 234  5 678  9  
|                                                                           |            |            |         |     |     |     |     |     |     |
|---------------------------------------------------------------------------|------------|------------|---------|-----|-----|-----|-----|-----|-----|
| PRINCIPAL INVESTIGATOR (LAST, FIRST, MIDDLE): Graves, Kristi, Dove        | Not at all | Moderately | Totally |     |     |     |     |     |     |
| confident                                                                 | confident  | confident  |         |     |     |     |     |     |     |
| Maintaining a sense of humor.                                             |  1        |  2        |  3     |  4 |  5 |  6 |  7 |  8 |  9 |
| caused by cancer treatment.                                               |  1        |  2        |  3     |  4 |  5 |  6 |  7 |  8 |  9 |
| Accepting physical changes or limitations  Seeking consolation.           |  1        |  2        |  3     |  4 |  5 |  6 |  7 |  8 |  9 |
| Reducing any nausea associated with  treatment (chemotherapy, radiation). |  1        |  2        |  3     |  4 |  5 |  6 |  7 |  8 |  9 |
| Maintaining hope.                                                         |  1        |  2        |  3     |  4 |  5 |  6 |  7 |  8 |  9 |
| Asking physicians questions.                                              |  1        |  2        |  3     |  4 |  5 |  6 |  7 |  8 |  9 |
| Doing something, anything.                                                |  1        |  2        |  3     |  4 |  5 |  6 |  7 |  8 |  9 |
| Managing pain.                                                            |  1        |  2        |  3     |  4 |  5 |  6 |  7 |  8 |  9 |
| Managing nausea and vomiting.                                             |  1        |  2        |  3     |  4 |  5 |  6 |  7 |  8 |  9 |
| Controlling my negative feelings about  cancer.                           |  1        |  2        |  3     |  4 |  5 |  6 |  7 |  8 |  9 |
appendix c treatment fidelity plan
section r familism scale -

The following questions pertain to your perception of family support. Using the scale below, we would like for you to answer to the next statements on a scale of 1 to 10, where 1 is strongly disagree and 10 strongly agree.  
| Strongly                                                                                                                                                                         | Strongly   |    |    |    |    |    |    |    |    |    |
|----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|------------|----|----|----|----|----|----|----|----|----|
| disagree                                                                                                                                                                         | agree      |    |    |    |    |    |    |    |    |    |
| A person should always live near  his or her parents and spend time  with them on a regular basis.                                                                               | 1          | 2  | 3  | 4  | 5  | 6  | 7  | 8  | 9  | 10 |
| A person should always support  members of the extended family,  for example, aunts, uncles, and inlaws, if they are in need even it is a  big sacrifice.                                                                                                                                                                                  | 1          | 2  | 3  | 4  | 5  | 6  | 7  | 8  | 9  | 10 |
| A person should rely on his or her                                                                                                                                               | 1          | 2  | 3  | 4  | 5  | 6  | 7  | 8  | 9  | 10 |
| family if the need arises A person should often do activities  with his or her immediate and  extended families, for example, eat  meals, play games, or go  somewhere together. | 1          | 2  | 3  | 4  | 5  | 6  | 7  | 8  | 9  | 10 |
| A person should help his or her  elderly parents in times of need, for  example, helping financially or  sharing a house.                                                        | 1          | 2  | 3  | 4  | 5  | 6  | 7  | 8  | 9  | 10 |
appendix c treatment fidelity plan
section s caregiver inventory -caregivers

The next questions are about things you might do when caring for a person with an illness. We are interested in how confident you are that you can do those things. Make sure your ratings reflect your confidence whether or not you have done these in the past. So, your rating should reflect your confidence that you could do these things in the future.. On a scale of 1 to 9, 1 meaning "not at all confident" and 9 meaning "totally confident, please tell me how confident you are that you can accomplish each behavior.  
| Totally  confiden t                                                                                                       |                        |     |     |     |     |     |     |     |     |
|---------------------------------------------------------------------------------------------------------------------------|------------------------|-----|-----|-----|-----|-----|-----|-----|-----|
| Coping with information overload.                                                                                         |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Listening and learning from the person as to  how to care better for her.                                                 |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Letting go of things I can't control.                                                                                     |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Expressing negative feelings about the  illness.                                                                          |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Maintaining hope.                                                                                                         |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Being able to notice the "good moments" in  caregiving when they occur.                                                   |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Allowing the person to have and express her  own feelings.                                                                |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| feeding, washing, dressing or using the toilet.                                                                           |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Assisting the person with activities, such as  Continuing to take care of yourself (for  example: exercise, diet, sleep). |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Talking openly and honestly with the person.                                                                              |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Continuing to engage in personal activities  that you like to do.                                                         |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Talking about death and dying.                                                                                            |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Providing emotional support to the person I'm  caring for.                                                                |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Understanding medical information from  doctors, nurses or other sources.                                                 |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Seeking support for yourself.                                                                                             |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Dealing with feelings of helplessness.                                                                                    |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| feelings toward you when they occur.                                                                                      |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Dealing with the person expressing negative  Assisting and encouraging the person in                                      |  1                    |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| following through with all treatments and  taking all prescribed medications.                                             | Moderatel y  confident |     |     |     |     |     |     |     |     |
| Not at all  confident                                                                                                     |                        |     |     |     |     |     |     |     |     |  
| PRINCIPAL INVESTIGATOR (LAST, FIRST, MIDDLE): Graves, Kristi, Dove   | Totally  confiden t   |     |     |     |     |     |     |     |     |
|----------------------------------------------------------------------|-----------------------|-----|-----|-----|-----|-----|-----|-----|-----|
| Asking physicians and nurses questions.                              |  1                   |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Dealing with criticism from others.                                  |  1                   |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Maintaining a close relationship with the  person I'm caring for. .  |  1                   |  2 |  3 |  4 |  5 |  6 |  7 |  8 |  9 |
| Moderatel y  confident                                               |                       |     |     |     |     |     |     |     |     |
| Not at all  confident                                                |                       |     |     |     |     |     |     |     |     |
appendix c treatment fidelity plan
section t demographics

This is the last section. We have some questions about you. You can skip any question you do not wish to answer; however this information is important for our study.  
What is your birth date? _____/_____/_____ (MM/DD/YY)
Hispanic/Latino 1 Non-Hispanic/Latino 2 Which is your ethnicity? Please choose one answer.  
What is your race? I will read a list and please tell me which one best describes you.  
| Check below                                                                                                                                                                          |
|--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| Black or African American White or Caucasian American Indian/Alaska Native Asian Native Hawaiian or other Pacific Islander More than One Race Don't Know/Unsure Prefer Not to Answer |  
What is the highest grade or level of schooling you have completed? Have you completed…  
| Check below         | Check  below                        |
|---------------------|-------------------------------------|
| No formal schooling | 11th grade                          |
| 1st grade           | 12th grade                          |
| 2nd grade           | College 1 year                      |
| 3rd grade           | College 2 years                     |
| 4th grade           | College 3 years                     |
| 5th grade           | College 4 years                     |
| 6th grade           | College 5 years                     |
| 7th grade           | College 6 years                     |
| 8th grade           | Training after high school          |
| 9th grade           | Other. Specify: ___________________ |
| 10th grade          |                                     |  
| Where or in which country where you born? Were you born in…. Check Below   | Check  Below                                                                                        |
|----------------------------------------------------------------------------|-----------------------------------------------------------------------------------------------------|
| Argentina                                                                  | México                                                                                              |
| Bolivia                                                                    | Nicaragua                                                                                           |
| Brasil                                                                     | Perú                                                                                                |
| Colombia                                                                   | Puerto Rico                                                                                         |
| Chile                                                                      | Republica Dominicana                                                                                |
| Ecuador                                                                    | United States. Which generation you are (first, second,  third?) Specify: _________________________ |
| El Salvador                                                                | Other (specify)                                                                                     |
| Guatemala                                                                  |                                                                                                     | How many years have you lived in the United States? _______________  
What is your current work status? Please select one. Are you…
Working part time Working full time Full- or part-time student Retired Never worked Unemployed/looking for work Receiving disability What is your average yearly household income (combined income of everyone living in your house)? Please choose the response that fits best.  
Less than $9,999  $60,000-$69,999  Don't know $10,000-$19,999  $70,000-$79,999 $20,000-$29,999  $80,000-$89,999 $30,000-$39,999  $90,000-$99,999 $40,000-$49,999  More than $100,000 $50,000-$59,999  Prefer not to answer What is your current marital status? (Select one)
Single Separated Divorced Widowed
Married
Living with a partner Do you have a doctor (primary care, family doctor) that you see regularly (routine check-ups, treatment of colds or minor health concerns)? ___ Yes ____ No Are you currently covered by health insurance? ____ Yes ____ No If no, skip next question.  
What type of health insurance do you have?  
______ Group insurance (through my work or my partner's work)
______ Government insurance (Medicare, Medicaid)
______ Military insurance ______ Private insurance
______ Not applicable; I do not currently have health insurance Have you ever been denied health insurance for any reason?  
If yes, why were you denied insurance?  
_____________________________________________________________________________
___________________________
Is there any other thing that we hadn't asked you that you want to share with us about what impacts our quality of life and your general wellness as a breast cancer survivor or caregiver?  
May we contact you in the future for other research studies? You would be free to participate or decline at that time.  
______ Yes, you may contact me about future research
______ No, I prefer not to be contacted about future research If Yes: Can you give us other additional telephone numbers or an email address where we can contact you? Please note this information will not be connected with your study data. _____________________________________________________________________________________  
To thank you for your time, please indicate which gift card you would like to receive:
Target Stores Safeway Foods (or other local grocery store) Amazon.com NOTE: These stores may change based on feedback from the team.  
These are all the questions that we had for you today. Thank you for taking the time to participate in this study. We hope that this will help other survivors and caregivers in the future.  
_____ Yes _____ No