CONSENT
Word In Black, a national newsroom and research group dedicated to informing and empowering the Black community, invites you to participate in a brief online survey designed to better understand community views on Breast Cancer. If you agree to take part, you will complete a 5-minute anonymous survey. Participation is entirely voluntary, and you may skip any question that is not marked as required or stop the survey at any time without penalty.
To make sure our results represent the community accurately, we ask a few basic questions about age, location, and race/ethnicity. There are no direct benefits or risks beyond possible emotional discomfort when reflecting on personal topics.
Your responses are confidential and stored on secure, password-protected servers. Contact information for incentives is kept separate from survey data.
You must be 18 or older to participate.
By selecting “I consent,” you confirm that you have read this information and agree to take part.
Questions? Email research@wordinblack.com
- I consent to participate
- I do not consent to participate
Section:
If they do not consent message:
Thank you for considering the study. Because you did not consent to be part of the study, you have been exited from the survey and can now close this tab.
QUALIFYING QUESTIONS
1. What is your race? *
(Select the option that best describes you.)
Question Type: Multiple Choice (Single-select)
- Black or African American
- White or Caucasian (screen out)
- Asian (screen out)
- Native Hawaiian or Other Pacific Islander (screen out)
- Indigenous / Native American or Alaska Native (screen out)
- Multiracial, including Black or African American
- Multiracial, not including Black or African American (screen out)
- Another race (please specify): ___________
- Prefer not to say (screen out)
2. How old are you?*
Question Type: Multiple Choice — Single Select
- Under 18 (screen out)
- 18–24
- 25–39
- 40–49
- 50–59
- 60 or older
3. What is your gender?*
Question Type: Multiple Choice — Single-Select
- Woman
- Man
- Transgender female
- Transgender male
- Prefer to self-describe: __________
- Prefer not to say (screen out)
4. In which state do you currently reside?
*Dropdown list of all 50 states, D.C., and Puerto Rico
Screening logic: If they don’t select Black or African American or Multiracial, including Black or African American, write in 18+, or select that their gender is female or Transgender male→ [Add “Go to section: Disqualification message”]
Section: Disqualification Message
Thank you for your interest. This survey is currently focused on the experiences of Black Women ages 18 and older. We appreciate your willingness to participate.
RISK AWARENESS AND RISK PERCEPTIONS
1. Have you or someone close to you ever been diagnosed with breast cancer?
Yes, I have had breast cancer
Yes, someone close to me has had breast cancer
No
Prefer not to say
2. Has a healthcare provider ever talked to you about getting a mammogram?
(Yes/No/I don’t remember)
3. Has a healthcare provider ever talked to you about genetic counseling or testing for inherited breast cancer risk (such as BRCA1 or BRCA2)?
(Yes/No/I don’t remember)
4. How often do you find yourself thinking about the possibility of developing breast cancer?
1 – Never
2 – Rarely
3 – Sometimes
4 – Often
5 – Almost all the time
5. I feel confident that I have enough knowledge to take actions to support my breast health and reduce risk.
1 – Strongly disagree
2 – Disagree
3 – Neither agree nor disagree
4 – Agree
5 – Strongly agree
