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This study is being conducted by the Department of Public Health at Oregon State University. It is for research purposes only. Your participation is confidential. Your name and information will NOT go on a mailing list or be passed on to other organizations.
We are conducting a survey of men age 18-40 about their knowledge and perceived health benefits regarding prostate cancer and breast cancer. The survey takes approximately 20 minutes to complete, and all participants who complete the survey are eligible to enter a drawing for one of two $50 cash prizes. Only participants who complete the survey by June 5, 2004 will be eligible to enter the drawing.

If you are interested in participating, please enter your confirmation number, and then click "Continue".

Confirmation Number

Note: Your
confirmation number can be found in the invitation you received to participate in
this study. Your confirmation number is a
unique 5 digit code, and is used to confirm
your eligibility for the $50 cash prize
drawing.

Informed Consent

Study Title: Prostate & Breast Cancer Survey

Principal Investigator: Rebecca
J. Donatelle, PhD, Department of Public Health

Student Researcher: Brian K.
Johnson, Department of Public Health

PURPOSE

This is a research study. The purpose of this
research study is to explore the knowledge and
health beliefs of men between the ages of 18 and
40 regarding prostate cancer, and breast cancer
in women. The purpose of this consent form is to
give you the information you will need to help
you decide whether to be in the study or not.
Please read the form carefully. You may ask any
questions about the research, what you will be
asked to do, the possible risks and benefits,
your rights as a volunteer, and anything else
about the research or this form that is not
clear. To do so, simply call 1-877-221-8424 or email [email protected]. When all of your questions have been
answered, you can decide if you want to be in
this study or not. This process is called
"informed consent". You may print a
copy of this form for your records.

We are inviting you to participate in this
research study because you are an adult male
between the ages of 18 and 40 years old.
Approximately 500 men like you will
participate in this study.

PROCEDURES

If you agree to participate, your involvement
will last for approximately 20-30 minutes. Once
you agree to participate in this study, you will
complete an on-line survey. Once you have
completed this survey, you will have completed
your involvement in this study.

RISKS

Risks to participants in this research will be
minimal. The greatest risk to participants is
loss of confidentiality or possible embarrassment
or distress due to others knowing of your
participation in this research. In addition, you
may worry that your answers on the survey are
incorrect.

BENEFITS

There may be no personal benefit for
participating in this study. However, the
researchers anticipate that, in the future,
society may benefit from this study by a greater
understanding of the current level of awareness
among men about prostate, testicular and breast
cancers. Such knowledge may suggest areas in
which health promotion and education efforts
could be enhanced or might be better directed.

COSTS AND COMPENSATION

You will not have any costs for participating in
this research project, and you will not be
compensated for participating in this research
project. If you choose, you may enter a drawing
for a $50 cash prize at the end of this survey.
All participants who complete the survey by June 5, 2004, will be
eligible to receive the $50 cash prize.

CONFIDENTIALITY

Records of participation in this research project
will be kept confidential to the extent permitted
by law. However, federal government regulatory
agencies and the Oregon State University
Institutional Review Board (a committee that
reviews and approves research studies involving
human subjects) may inspect and copy records
pertaining to this research. It is possible that
these records could contain information that
personally identifies you. In the event of any
report or publication from this study, your
identity will not be disclosed. Results will be
reported in a summarized manner in such a way
that you cannot be identified.

VOLUNTARY PARTICIPATION

Taking part in this research study is voluntary.
You may choose not to take part at all. If you
agree to participate in this study, you may stop
participating at any time. You are free to skip
any questions that you would prefer not to
answer. If you decide not to take part, or if you
stop participating at any time, your decision
will not result in any penalty or loss of
benefits to which you may otherwise be entitled.

QUESTIONS

Questions are encouraged. If you have any
questions about this research project, please
contact: Brian K. Johnson, at 1-877-221-8424 or email [email protected]. If you have questions
about your rights as a participant, please
contact the Oregon State University Institutional
Review Board (IRB) Coordinator, at (541) 737-3437
or by e-mail at [email protected] or by mail at
312 Kerr Administration Building, Corvallis, OR
97331-2140.

By clicking "I agree" below, you are
indicating that you have read the above consent
statement, that your questions have been
answered, and that you agree to take part in this
study. You may print a copy of this form by
clicking the print button on your Internet
browser.

I agree. I wish to participate in this study.

I do not agree. I do not wish to participate in this study.

Are you:

Male

Female

How old are you?

Are you a doctor or a nurse?

Yes

Have you ever been tested for prostate cancer?

Yes

I don't know

Have you ever been diagnosed with prostate cancer?

Yes

I don't know

To your knowledge, has a friend or family member ever been tested for prostate cancer?

Yes

I don't know

If yes, what is the person(s) relationship to you? (select all that apply)

Partner / Spouse

Grandfather

Father

Brother

Uncle

Other Family Member

Friend

Other

To your knowledge, has a friend or family member ever been diagnosed with prostate cancer?

Yes

I don't know

If yes, what is the person(s) relationship to you? (select all that apply)

Partner / Spouse

Grandfather

Father

Brother

Uncle

Other Family Member

Friend

Other

To your knowledge, has a friend or family member ever been tested for breast cancer?

Yes

I don't know

If yes, what is the person(s) relationship to you? (select all that apply)

Female Partner / Spouse

Grandmother

Mother

Sister

Aunt

Other Female Family Member

Female Friend

Male Partner / Spouse

Grandfather

Father

Brother

Uncle

Other Male Family Member

Male Friend

Other

To your knowledge, has a friend or family member ever been diagnosed with breast cancer?

Yes

I don't know

If yes, what is the person(s) relationship to you? (select all that apply)

Female Partner / Spouse

Grandmother

Mother

Sister

Aunt

Other Female Family Member

Female Friend

Male Partner / Spouse

Grandfather

Father

Brother

Uncle

Other Male Family Member

Male Friend

Other

Are you currently:
(select all that apply)

Employed full-time

Employed part-time

A student

Unemployed

A Homemaker

Retired

Other

Are you currently:

Single

Married

Divorced

Separated

Widowed

Which of the following includes your TOTAL family income in the year 2003 before taxes?

Up to $10,000

$10,000 - $19,999

$20,000 - $29,999

$30,000 - $39,999

$40,000 - $49,999

$50,000 - $74,999

More than $75,000

What is the last grade of school or year of college you completed?

Grade school or less (grade 1-8)

Some high school (grade 9-11)

Graduated High School (grade 12)

Vocational School / Technical School

Some College (2 years or less)

Some College (more than 2 years)

Graduated College

Post-Graduate

Are you of Hispanic or Latino Heritage?

Yes

What is your race?

Caucasian / Euro-American

African American

Hispanic

American Indian or Alaskan Native

Asian or Pacific Islander

Other

Would you say that in general your health is:

Excellent

Very Good

Good

Fair

Poor

Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs or government plans such as Medicare?

Yes

How much do you weigh? (please specify in pounds)

About how tall are you without shoes? (please specify in feet and inches)


Feet

Inches

If you had questions about prostate cancer, how much would you trust the following sources to help answer your questions?

	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely
Television / Radio	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

Magazine / Newspaper	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

Internet	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

Books / Library	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

Doctor / Nurse / Pharmacist	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

Friend / Co-Worker	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

Spouse / Partner	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

Family Member	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

Other	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

If you had questions about breast cancer, how much would you trust the following sources to help answer your questions?

	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely
Television / Radio	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

Magazine / Newspaper	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

Internet	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

Books / Library	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

Doctor / Nurse / Pharmacist	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

Friend / Co-Worker	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

Spouse / Partner	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

Family Member	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

Other	Not at all	Somewhat	Slightly	Moderately	A lot	Very much	Completely

Have you ever discussed prostate cancer with the following individuals?

	Yes	No	Does not apply
Spouse / Partner	Yes	No	Does not apply

Friend	Yes	No	Does not apply

Relative	Yes	No	Does not apply

Co-worker	Yes	No	Does not apply

Sibling	Yes	No	Does not apply

Doctor	Yes	No	Does not apply

Nurse	Yes	No	Does not apply

Pharmacist	Yes	No	Does not apply

Have you ever discussed breast cancer with the following individuals?

	Yes	No	Does not apply
Spouse / Partner	Yes	No	Does not apply

Friend	Yes	No	Does not apply

Relative	Yes	No	Does not apply

Co-worker	Yes	No	Does not apply

Sibling	Yes	No	Does not apply

Doctor	Yes	No	Does not apply

Nurse	Yes	No	Does not apply

Pharmacist	Yes	No	Does not apply

Who helps you to make health care decisions, if anyone? (select all that apply)

Spouse / Partner

Friend

Relative

Co-worker

Sibling

Doctor

Nurse

Pharmacist

I make my own decisions

Other

Where do you usually get information on health-related issues? (select all that apply)

Television

Radio

Magazine / Newspaper

Internet

Books / Library

Health Care Provider

Friend / Co-worker

Spouse / Partner

Other Family Member

Other

Please rate how likely you believe the following to be:

	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely
I will develop prostate cancer in my lifetime.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

In the next year, I will see my physician for a regular preventative health examination.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

In the next year, I will talk with my physician about prostate cancer.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

In the next year, I will talk with a friend or family member about prostate cancer.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

	Much less likely	Slightly less likely	About the same	Slightly more likely	Much more likely
Compared to other men, what is your chance of developing prostate cancer?	Much less likely	Slightly less likely	About the same	Slightly more likely	Much more likely

In the past 6 months, have you read, seen or heard anything about prostate cancer?

Yes

In the past 6 months, have you read, seen or heard anything about breast cancer?

Yes

Do you have a prostate gland?

Yes

I don't know

What is the prostate gland's function (what does it do)?

On a scale from one to ten, with one being not at all knowledgeable, and 10 being extremely knowledgeable, how knowledgeable do you think you are about:

	Not at all Knowledgeable (1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)	Extremely Knowledgeable (10)
Prostate Cancer	Not at all Knowledgeable (1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)	Extremely Knowledgeable (10)

Breast Cancer	Not at all Knowledgeable (1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)	Extremely Knowledgeable (10)

In the last 12 months, how often have you...

	Daily	3-5 times a week	Once or twice a week	Once or twice a month	Never
Dieted to lose weight	Daily	3-5 times a week	Once or twice a week	Once or twice a month	Never

Smoked cigarettes	Daily	3-5 times a week	Once or twice a week	Once or twice a month	Never

Consumed alcohol	Daily	3-5 times a week	Once or twice a week	Once or twice a month	Never

For each of the following factors, how likely do you believe they are to increase a man's risk of developing prostate cancer?

	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely
Smoking	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Drinking	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Eating a high fat diet	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Pollution / Toxic Chemicals	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Stress	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

A family history or genetics	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Too much sexual activity	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Aging	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Lack of exercise	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Being overweight	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

For each of the following factors, how likely do you believe they are to increase a woman's risk of developing breast cancer?

	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely
Smoking	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Drinking	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Eating a high fat diet	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Pollution / Toxic Chemicals	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Stress	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

A family history or genetics	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Too much sexual activity	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Aging	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Lack of exercise	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Being overweight	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely
Having large breasts	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Giving birth to first child after the age of 30	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Menarche (start of period) before age 12	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Menopause late in life	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

Use of oral contraceptives	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

A bump or blow to the breast	Not at all likely	Slightly likely	Somewhat likely	Moderately likely	Quite likely	Very likely	Extremely likely

According to the American Cancer Society, at what age should:

	Never, it is not recommended	20 years old	30 years old	40 years old	50 years old	I don't know
A man begin to have a blood test for prostate cancer on a regular basis?	Never, it is not recommended	20 years old	30 years old	40 years old	50 years old	I don't know

A man begin to have a physician examine his prostate by gently pressing on the prostate for cancer on a regular basis?	Never, it is not recommended	20 years old	30 years old	40 years old	50 years old	I don't know

A man begin to examine his prostate for cancer on a regular basis?	Never, it is not recommended	20 years old	30 years old	40 years old	50 years old	I don't know

A woman begin to have a blood test for breast cancer on a regular basis?	Never, it is not recommended	20 years old	30 years old	40 years old	50 years old	I don't know

A woman begin to have an x-ray of her breasts to detect breast cancer on a regular basis?	Never, it is not recommended	20 years old	30 years old	40 years old	50 years old	I don't know

A woman begin to have a physician examine her breasts by gently feeling the breasts for cancer on a regular basis?	Never, it is not recommended	20 years old	30 years old	40 years old	50 years old	I don't know

A woman begin to examine her breasts for cancer on a regular basis?	Never, it is not recommended	20 years old	30 years old	40 years old	50 years old	I don't know

Please read each statement, and indicate whether you believe the statement is true or false.

	True	False
Prostate cancer is the second leading cause of death due to cancer in men, exceeded only by lung cancer.	True	False

Besides skin cancer, prostate cancer is the most common type of cancer among all men.	True	False

Prostate cancer is a disease that cannot be prevented.	True	False

There are no early warning signs of prostate cancer.	True	False

A man's likelihood of survival is better if prostate cancer is detected early.	True	False

There is no cure for prostate cancer.	True	False

All men are just as likely to get prostate cancer regardless or race.	True	False

Prostate cancer runs in families.	True	False

A man can have prostate cancer without pain or any other symptoms.	True	False

Older men are more likely to develop prostate cancer than younger men.	True	False

	True	False
Eating a low fat diet can help prevent prostate cancer.	True	False

Please read each statement, and indicate whether you believe the statement is true or false.

	True	False
Breast cancer is the second leading cause of death due to cancer in women, exceeded only by lung cancer.	True	False

Besides skin cancer, breast cancer is the most common type of cancer among all women.	True	False

Breast cancer is a disease that cannot be prevented.	True	False

There are no early warning signs of breast cancer.	True	False

A woman's likelihood of survival is better if breast cancer is detected early.	True	False

There is no cure for breast cancer.	True	False

All women are just as likely to get breast cancer regardless of race.	True	False

Breast cancer runs in families.	True	False

A woman can have breast cancer without pain or any other symptoms.	True	False

Older women are more likely to develop breast cancer than younger women.	True	False

	True	False
Eating a low fat diet can help prevent breast cancer.	True	False

My discussing prostate cancer with others will / would:

	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely
Be embarrassing.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

Be inconvenient.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

Be time consuming.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

Please my family.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

Bring me peace of mind.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

Help me live a longer life.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

Help me learn about prostate cancer.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

My having a preventative examination on a regular basis will / would:

	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely
Be embarrassing.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

Be physically uncomfortable.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

Be inconvenient.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

Be time consuming.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

Be expensive.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

Ensure that prostate cancer is detected before it has spread throughout my body (metastasized).	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

Please my family.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

Bring me peace of mind.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

Help me live a longer life.	Extremely unlikely	Moderately unlikely	Slightly unlikely	Neither likely nor unlikely	Slightly likely	Moderately likely	Extremely likely

Please rate your opinion of how good or bad the following would be for you:

	Extremely bad	Moderately bad	Slightly bad	Neither bad nor good	Slightly good	Moderately good	Extremely good
My being embarrassed.	Extremely bad	Moderately bad	Slightly bad	Neither bad nor good	Slightly good	Moderately good	Extremely good

My being physically uncomfortable.	Extremely bad	Moderately bad	Slightly bad	Neither bad nor good	Slightly good	Moderately good	Extremely good

My being inconvenienced.	Extremely bad	Moderately bad	Slightly bad	Neither bad nor good	Slightly good	Moderately good	Extremely good

My spending a lot of time at a medical appointment.	Extremely bad	Moderately bad	Slightly bad	Neither bad nor good	Slightly good	Moderately good	Extremely good

My spending a lot of money on medical services.	Extremely bad	Moderately bad	Slightly bad	Neither bad nor good	Slightly good	Moderately good	Extremely good

Detecting cancer before it has spread throughout my body (metastasized).	Extremely bad	Moderately bad	Slightly bad	Neither bad nor good	Slightly good	Moderately good	Extremely good

My pleasing my family.	Extremely bad	Moderately bad	Slightly bad	Neither bad nor good	Slightly good	Moderately good	Extremely good

My having peace of mind.	Extremely bad	Moderately bad	Slightly bad	Neither bad nor good	Slightly good	Moderately good	Extremely good

My living a longer life.	Extremely bad	Moderately bad	Slightly bad	Neither bad nor good	Slightly good	Moderately good	Extremely good

If the following events or conditions were to happen to you, how serious do you believe each would be for you personally?

	Not at all serious	Slightly serious	Somewhat serious	Quite serious	Very serious	Extremely serious
Prostate cancer	Not at all serious	Slightly serious	Somewhat serious	Quite serious	Very serious	Extremely serious

Frequent pain in my back, pelvis, or upper thighs	Not at all serious	Slightly serious	Somewhat serious	Quite serious	Very serious	Extremely serious

My inability to urinate	Not at all serious	Slightly serious	Somewhat serious	Quite serious	Very serious	Extremely serious

My dying from prostate cancer	Not at all serious	Slightly serious	Somewhat serious	Quite serious	Very serious	Extremely serious

Cancer that has spread (metastasized) to multiple parts of my body	Not at all serious	Slightly serious	Somewhat serious	Quite serious	Very serious	Extremely serious

Frequent pain in my bones or joints	Not at all serious	Slightly serious	Somewhat serious	Quite serious	Very serious	Extremely serious

My loss of work or income due to illness	Not at all serious	Slightly serious	Somewhat serious	Quite serious	Very serious	Extremely serious

Untreated prostate cancer	Not at all serious	Slightly serious	Somewhat serious	Quite serious	Very serious	Extremely serious

Impotence	Not at all serious	Slightly serious	Somewhat serious	Quite serious	Very serious	Extremely serious

Thank you for participating in this research
project.

You are now eligible to enter in the $50 Cash Prize
Drawing. Two eligible participants will be randomly selected to receive a $50 cash prize.

To enter in the drawing, please provide your name and
contact information. This information will be used to
contact you in the event you are selected to receive
the $50 cash prize. This information will not be
shared with others, and you will not be placed on a
mailing list.

You must agree to abide by the rules on this page to
continue to be eligible for the prize.

Rules

1. You may only enter the contest once, after
completing the survey.

2. This contest is not valid where not legal.

3. Winners will be selected by placing all received
entries in a box, and picking two at random.

4. Odds of winning will depend upon how many people
take the survey by the closing date of the contest (June 5, 2004).

5. Winners will be notified by mail during the week of June 7-11, 2004.

6. If an entry is deemed to be suspicious, or
fraudulent or in violation of any of the rules in any
way, it will be rejected.

7. The judge's decision is final, and no correspondence
will be entered into regarding their decisions.

8. Prizes will be awarded by check.

9. Only one entry is eligible per household.

10. We are not responsible for erroneous, incomplete,
lost or stolen entries or prizes. We are not
responsible for entries affected by network or
computer errors.

11. Only individuals residing in the USA are eligible
for entry.

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