Eligibility Script for Pretest and Main Study

Attachment G: Eligibility Script for Pretest and Main Study

Form Approved

OMB No. __0920-XXX__

Exp. Date _xx/xx/20xx_

Respondent No. ___________

Hi, I’m _________________. I work for the Research Collaborative Unit here.

Do you speak English?

(If no)  That’s o.k. Thank you. STOP

(If yes)  Great. Thank you. We’re doing a study on women’s health.

Do you have access to a phone where we can call you to ask you some questions?

(If no)  That’s o.k. Thank you. STOP

(If yes)  Good. Thank you.

Research Assistant will determine, by observation, if patient is ineligible because of impending labor (only for Pretest); visual, hearing, or mental impairment; or accompanied by a child over age three with no other adult supervision or a companion who refuses to separate from her.

(If not eligible) Patient will be thanked.

(If eligible) We’d like to invite you to participate in our study  (Continue with consent form).