Screening Form (NC)

Appendix Q – Screening form_NC – page 5

Appendix Q

Form Approved

OMB No.

Exp. Date

Screening Form for Focus Group with Women (North Carolina)

ID Number: Staff name: __________________________

Date: _________________ Time: ________________

Instructions: Screener instructions are indicated on the form below. Read statements in italics to the potential participant. Write responses directly on this form. Do not write the participant’s name or contact information on this form. Contact information must be recorded separately on the Contact Sheet and the participant’s ID number written on this form.

I. APPROACHING THE POTENTIAL PARTICIPANT

“Hi, I’m _______ with the [project name]. I would like to talk to you about a research study we are conducting at the Centers for Disease Control and Prevention. Is now a good time to tell you about the project to see if you would like to participate in it?

1) Yes “Good” – Continue to Section II, page 7.

2) No, this time doesn’t work, but person is interested.

- Get her phone number and [1] ask for a good time to call; [2] ask if it is okay to leave a message OR Give her the study phone number. Document this on the Participant Contact Form.

- When calling the person, use the script starting in Section II, page 7. However, if you call the person and do NOT reach the person, then call the person again later or leave a message stating

“We are calling from ____ because you told us that you might be interested in participating in a research study. Please call us back at [local number] at your convenience or leave us a message telling us what is the best time to call you.”

- Log this information on the Participant Contact Form.

3) Person is not interested in the program. Thank the person and leave.

Public reporting burden of this collection of information is estimated to average 8 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-XXXX).

II. INTRODUCING THE STUDY

Say to the participant:

A. "I want to thank you for your interest in our study. First, I’m going to tell you a little bit about the study. Then, if you’re still interested, I’ll ask you some questions to assure that you are eligible to participate in this phase of the study.”

“First, about the study: We are researchers from the Centers for Disease Control and Prevention in Atlanta. Our research team would like to gather information from young African American women living in xxx County, North Carolina, to design a program that would help women improve their incomes and also make healthy decisions about their lives.”

Read the description below.

B. FOCUS GROUP Description

“What we are doing now is asking young African American women in xxx County to be in a group where they will be asked to talk about women and work in your community. This will involve coming to [name of location] and being in the group for about 2 hours. You will be reimbursed $25 for your time and effort. Up to 8 other young African American women will be in this group. Information you share in the focus group will be kept secure by the research staff. We will ask all participants to keep information shared in the focus group private, although we cannot guarantee that other participants will keep information private. There will be up to 3 women staff in the same room, and the focus group will be audiotaped.”

C. “Does this sound like something you’d be interested in participating in?”

1) Yes “Good.” Go to Section III, A (below).

2) No, person is not interested in the program. Skip to Section III, J, page 9.

III. SCREENING (Only after the potential participant has been told about the focus group)

- If a person being screened is ineligible at any point in the process, thank them for their time and interest, and explain that we have to limit the number of people we enroll in the research due to our recruitment criteria.

A. “Do you feel comfortable right now answering a few personal questions so that I can determine whether you are eligible to participate?”

1) Yes “Good. Let’s start with a few brief questions.”

2) Not a good time, but later "Is it okay of us to call you at a different time?”

- Get her phone number

- Ask for a good time to call

- Ask if it is okay to leave a message OR Give her the study phone number.

- Document this on the Participant Contact Form.

3) No, participant doesn’t want to be screened – Skip to Section III, J, page 9.

B. "How old are you?” Years old (INELIGIBLE if under 18)

C. “Do you consider yourself to be African American or black?”

1) Yes - Keep screening

2) No – INELIGIBLE

D. “Have you been sexually active in the last 90 days?”

1) Never– INELIGIBLE

2) More than 90 days ago– INELIGIBLE

3) 90 days or less – Keep screening

If D=3 ask

E. “Does this sex partner help to support you financially, for example, give you money for food, clothing, or housing expenses”

1) Yes – Keep screening

2) No – INELIGIBLE

F. “Do you a regular full-time job?”

1) Yes – INELIGIBLE

2) No – Keep screening

G. “Would you feel comfortable participating in group discussions that will be conducted in English?”

1) Yes

2) No - INELIGIBLE

H. Is this person eligible?

1) Yes

2) No – doesn’t meet study criteria

If NO:

"I want to thank you for talking with me, but unfortunately, you are not eligible for the study at this time. Due to the nature of this research, we’re limited in terms of the numbers of people we can enroll due to our recruitment criteria.

- If any community service resources are needed and available, provide them or referrals to them. - Thank the person and leave.

If YES:

“It looks like you are eligible for the study. Are you still interested in participating?”

1) Yes – go to question I.

2) No – go to question J.

I. Get or verify contact information, record it on the Participant Contact Form. Give directions to the focus group and date and time of the focus group to the participant. Also say:

"We would like to thank you for helping us with our study. Again, I want to remind you that all of the information that you gave us is secure to the extent permitted by law. Would you like us to give you a reminder call before the group session? Will you need transportation to get to the group session?”

1) YES – Note that on the Participant Contact Form.

2) No – Note that on the Participant Contact Form.

End screening.

J. Person decides not to participate at any point:

"Thank you for taking the time to talk with me today. You don’t have to answer the next question if you do not wish, but it would be useful for us to know why you do not want to participate."

1) Not interested in study topic

2) Study topic too sensitive/personal

3) Scheduling difficulties

4) Concerned about confidentiality

5) Not comfortable participating in groups

6) Other:

- If any community service resources are needed and available, provide them or referrals to them. - Thank the person and leave.

End screening.