OMB BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0524. The time to complete this information collection is estimated to average 15 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.
USDA/FNS
Focus Group Screening Questionnaire – Low-Income Mothers
RESEARCH CONTACT: Taryn Antigone at 202-973-3623 or [email protected]
DATES: TBD
SPECS:
Three, 90-minute focus groups with low-income mothers:
Moms with at least one non-school aged child (i.e., 2-5 years of age and not yet in kindergarten) – (2)
Moms with at least one child in elementary school, up to 10 years of age – (1)
Recruit 12 for 8 to show at each group.
Each woman must be in a low income household (see Q14 and Q15).
All respondents must speak English.
All respondents must be outgoing, responsive, articulate, willing and able to read and react to written materials, and must be willing to speak openly in a group.
PLEASE SCHEDULE/RECRUIT RESPONDENTS AS FOLLOWS:
|
GROUP |
DATE* |
TIME |
LOCATION |
[ ] |
Group 1: low-income mothers of non-school aged children |
|
|
Los Angeles |
[ ] |
Group A: low-income mothers of non-school aged children |
|
|
Los Angeles |
[ ] |
Group 2: low-income mothers with at least one child in elementary school |
|
|
Los Angeles |
[ ] |
Group 3: low-income mothers with at least one child in elementary school |
|
|
Chicago |
[ ] |
Group 4: low-income mothers of non-school aged children |
|
|
Chicago |
[ ] |
Group B: low-income mothers of non-school aged children |
|
|
Chicago |
[ ] |
Group 5: low-income mothers of non-school aged children |
|
|
Birmingham |
[ ] |
Group C: low-income mothers of non-school aged children |
|
|
Birmingham |
[ ] |
Group 6: low-income mothers with at least one child in elementary school |
|
|
Birmingham |
[LETTERED GROUPS = DIVISION OF FEEDING RESPONSIBILITY SESSIONS]
Hello, my name is _____with______. We are conducting a study about nutrition on behalf of the federal government, and I would like to ask you a few questions. I’m not trying to sell you anything. We would like to invite a number of women in your area to participate in a focus group to help us understand more about what they think about nutrition and health. May I speak to the female head of household? This should only take a few minutes. ONCE HEAD OF HOUSEHOLD ON PHONE, REPEAT INTRODUCTION AND READ OMB STATEMENT (see top of screener).
Record Gender—DO NOT ASK UNLESS UNABLE TO TELL.
Female…… |
[ ] |
Continue |
Male …….. |
[ ] |
Terminate |
Do you, or does anyone in your household, work for a radio station, television station, newspaper, market research company, advertising or public relations company?
Yes…… |
[ ] |
Terminate |
No…….. |
[ ] |
Continue |
Do you have any children under age 19 living at home?
Yes………… |
[ ] |
Continue |
No …….….. |
[ ] |
Terminate |
How old are your children? [check all that apply]
Under 2………… |
[ ] |
|
2-5 years old.….. |
[ ] |
If one of these is checked, continue. If not, terminate. |
6-10 years old.…. |
[ ] |
|
11 and up…...….. |
[ ] |
|
[If child is between the ages of 2-5, ASK] Is your child in Kindergarten?
Yes………………. |
[ ] |
Recruit for older group |
No.……………… |
[ ] |
Recruit for younger group |
[If child is between the ages of 6-10, ASK] What grade is your child in?
____________ [Record answer] Recruit for older group
Do you or does anyone in your household work in any of the following industries? [Record each “yes” response.]
Healthcare…………………………… |
[ ] |
Terminate if “YES” to any |
Nutrition………………….. |
[ ] |
|
Fitness………………………….. |
[ ] |
Have you ever participated in a focus group or been paid to be part of a discussion group?
Yes……..……………… |
[ ] |
Continue |
No……………………… |
[ ] |
Skip to Q10 |
How recently did you
participate in a focus group?
Less than 6 months ago |
[ ] |
Terminate |
6 months ago or longer |
[ ] |
Continue |
Generally speaking, do you consider yourself to be an “expert” in nutrition?
No…………………. |
[ ] |
Continue |
Yes …….…….…… |
[ ] |
Terminate |
Don’t know/Refused... |
[ ] |
Terminate |
Do you or your child(ren) have any health condition where you have to eat a special diet, cannot eat certain foods or have a diet prescribed by your doctor?
No…………………. |
[ ] |
Continue |
Yes …….…….…… |
[ ] |
Terminate |
Are you a vegetarian or vegan?
No…………………. |
[ ] |
Continue |
Yes …….…….…… |
[ ] |
Terminate |
Who does most of the grocery shopping or makes the shopping lists in your household? [DO NOT READ RESPONSES]
You…………………. |
[ ] |
Continue |
Someone else…….…….…… |
[ ] |
Terminate |
Including yourself, how many people currently live in your household?
__________ [Record answer]
What is your total annual household income? [Do not read list]
Less than $19,000………… |
1 |
Record number below |
$19,000 - $25,000………… |
2 |
Record number below |
$25,001 - $32,000………… |
3 |
Record number below |
$32,001 - $38,000………… |
4 |
Record number below |
$38,001 - $45,000………… |
5 |
Record number below |
$45,001 - $51,000………… |
6 |
Record number below |
$51,001 - $58,000………… |
7 |
Record number below |
$58,001 - $64,000………… |
8 |
Record number below |
More than $64,000……….. |
[ ] |
Terminate |
Don’t know/Refused ……... |
[ ] |
Terminate |
Answer to question 14: ____________ Answer to question 15: _______________
Accept respondent if he/she falls into one of the following categories:
___ Has 1 person in household (Q14), and answer to Q15 is 1.
___ Has 2 people in household (Q14), and answer to Q15 is 1 or 2.
___ Has 3 people in household (Q14), and answer to Q15 is 1, 2, or 3
___ Has 4 people in household (Q14), and answer to Q15 is 1, 2, 3, or 4
___ Has 5 people in household (Q14), and answer to Q15 is 1, 2, 3, 4, or 5.
___ Has 6 people in household (Q14), and answer to Q15 is 1, 2, 3, 4, 5, or 6.
___ Has 7 people in household (Q14), and answer to Q15 is 1, 2, 3, 4, 5, 6, or 7.
___ Has 8+ people in household (Q14), and answer to Q15 is 1, 2, 3, 4, 5, 6, 7, or 8.
[INTERVIEWER, RECORD WHICH CATEGORY RESPONDENT FALLS INTO]
What is your current age? [Do not read list]
Under 18………… |
[ ] |
Terminate |
18-34 …….……... |
[ ] |
Record |
35-50…….……… |
[ ] |
|
50+ ……... |
[ ] |
Terminate |
Are you of Hispanic or Latino origin?
No…………………. |
[ ] |
Continue |
Yes …….…….…… |
[ ] |
Continue |
What is your race? (READ LIST. ACCEPT MULTIPLE ANSWERS.)
American Indian or Alaska Native………... |
[ ] |
|
Asian ….…….……………………………. |
[ ] |
|
Black or African American …….……… |
[ ] |
|
Native Hawaiian or Other Pacific Islander.. |
[ ] |
|
White……………………………………… |
[ ] |
Recruit no more than 5* |
*Using questions 17 and 18, recruit no more than 5 white, non-Hispanic respondents for each group. The remaining 7 recruits can be any mix of other races, but should not all be of one racial or ethnic group. To the extent possible, these 7 should be split between Hispanics and African Americans.
What is the highest level of education you have completed? [Do not read list]
High school graduate or less.…….…. |
[ ] |
Recruit a mix |
Some college, vocational or technical school………………………………... |
[ ] |
|
College graduate…………… |
[ ] |
Recruit no more than 3 |
Post graduate education (e.g., Master’s degree, MBA, law degree, PhD) |
[ ] |
Terminate |
How comfortable would you be reading an information pamphlet that is written in English and telling someone what you think about it?
Very comfortable.…….…. |
[ ] |
Continue |
Somewhat comfortable……………………... |
[ ] |
Continue |
Somewhat uncomfortable…………… |
[ ] |
Terminate |
Very uncomfortable…………… |
[ ] |
Terminate |
Are you currently employed?
Yes, full-time……………... |
[ ] |
Recruit a mix of employed and not employed |
Yes, part-time……………… |
[ ] |
|
No………………………… |
[ ] |
Are you ……….
Married………………………... |
[ ] |
Recruit a mix |
Single, never married ………… |
[ ] |
|
Separated/divorced/widowed… |
[ ] |
Are you or your child participating in any one of the following nutrition programs? [select all that apply]
Food Stamp Program……….............................. |
[ ] |
Record |
Free- or Reduced-price School Lunch ………… |
[ ] |
|
Women, Infants, and Children Program (WIC)… |
[ ] |
Take a moment and think about your health. What is the biggest concern you have about your health and why?
Recruiter: After recording respondent’s answer, determine whether or not you feel this respondent would be useful in the group. Did she:
Give full and complete answer?
Answer enthusiastically?
Speaks understandable English/is comfortable with the English language
It is most important that respondent be articulate!! If not, terminate.
I would like to invite you to participate in a group discussion that will be held at our facility on (DATE) at (TIME). The group will last approximately 90 minutes. To help cover costs such as transportation to the focus group site and child care, you will receive [INSERT INCENTIVE] in cash at the end of the group session. Would you be willing to participate?
Yes……………( ) SCHEDULE No……………..( ) TERMINATE
I will call you to remind you of this appointment. However, if for some reason you are unable to attend, please call me at (TELEPHONE NUMBER) so that I can find a replacement for you. Thank You.
Respondent’s name: ___________________________________________
Address: ____________________________________________________
Telephone # (Home): __________________ (Work) _________________
Recruited by: _________________________________________________
OMB BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0524. The time to complete this information collection is estimated to average 15 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.
USDA/FNS
Focus Group Screening Questionnaire – Low-Income Mothers
RESEARCH CONTACT: Taryn Antigone at 202-973-3623 or [email protected]
DATES: TBD
SPECS:
One, 90-minute focus groups with low-income mothers:
Moms with at least one non-school aged child (i.e., 2-5 years of age and not yet in kindergarten)
Recruit 12 for 8 to show at each group.
Each woman must be in a low income household (see Q14 and Q15).
All respondents must speak English.
All respondents must be outgoing, responsive, articulate, willing and able to read and react to written materials, and must be willing to speak openly in a group.
PLEASE SCHEDULE/RECRUIT RESPONDENTS AS FOLLOWS:
|
GROUP |
DATE* |
TIME |
LOCATION |
[ ] |
Group 1: low-income mothers of non-school aged children |
|
|
Raleigh |
[ ] |
Group 2: low-income mothers of non-school aged children |
|
|
Tampa |
[ ] |
Group 3: low-income mothers of non-school aged children |
|
|
San Antonio |
Hello, my name is _____with______. We are conducting a study about nutrition on behalf of the federal government, and I would like to ask you a few questions. I’m not trying to sell you anything. We would like to invite a number of women in your area to participate in a focus group to help us understand more about what they think about nutrition and health. May I speak to the female head of household? This should only take a few minutes. ONCE HEAD OF HOUSEHOLD ON PHONE, REPEAT INTRODUCTION AND READ OMB STATEMENT (see top of screener).
Record Gender—DO NOT ASK UNLESS UNABLE TO TELL.
Female…… |
[ ] |
Continue |
Male …….. |
[ ] |
Terminate |
Do you, or does anyone in your household, work for a radio station, television station, newspaper, market research company, advertising or public relations company?
Yes…… |
[ ] |
Terminate |
No…….. |
[ ] |
Continue |
Do you have any children under age 19 living at home?
Yes………… |
[ ] |
Continue |
No …….….. |
[ ] |
Terminate |
How old are your children? [check all that apply]
Under 2………… |
[ ] |
|
2-5 years old.….. |
[ ] |
If one of these is checked, continue. If not, terminate. |
6-10 years old.…. |
[ ] |
|
11 and up…...….. |
[ ] |
|
[If child is between the ages of 2-5, ASK] Is your child in Kindergarten?
Yes………………. |
[ ] |
Recruit for older group |
No.……………… |
[ ] |
Recruit for younger group |
[If child is between the ages of 6-10, ASK] What grade is your child in?
____________ [Record answer] Recruit for older group
Do you or does anyone in your household work in any of the following industries? [Record each “yes” response.]
Healthcare…………………………… |
[ ] |
Terminate if “YES” to any |
Nutrition………………….. |
[ ] |
|
Fitness………………………….. |
[ ] |
Have you ever participated in a focus group or been paid to be part of a discussion group?
Yes……..……………… |
[ ] |
Continue |
No……………………… |
[ ] |
Skip to Q10 |
How recently did you
participate in a focus group?
Less than 6 months ago |
[ ] |
Terminate |
6 months ago or longer |
[ ] |
Continue |
Generally speaking, do you consider yourself to be an “expert” in nutrition?
No…………………. |
[ ] |
Continue |
Yes …….…….…… |
[ ] |
Terminate |
Don’t know/Refused... |
[ ] |
Terminate |
Do you or your child(ren) have any health condition where you have to eat a special diet, cannot eat certain foods or follow a diet prescribed by your doctor?
No…………………. |
[ ] |
Continue |
Yes …….…….…… |
[ ] |
Terminate |
Are you a vegetarian or vegan?
No…………………. |
[ ] |
Continue |
Yes …….…….…… |
[ ] |
Terminate |
Who does most of the grocery shopping or makes the shopping lists in your household? [DO NOT READ RESPONSES]
You…………………. |
[ ] |
Continue |
Someone else…….…….…… |
[ ] |
Terminate |
Including yourself, how many people currently live in your household?
__________ [Record answer]
What is your total annual household income? [Do not read list]
Less than $19,000………… |
1 |
Record number below |
$19,000 - $25,000………… |
2 |
Record number below |
$25,001 - $32,000………… |
3 |
Record number below |
$32,001 - $38,000………… |
4 |
Record number below |
$38,001 - $45,000………… |
5 |
Record number below |
$45,001 - $51,000………… |
6 |
Record number below |
$51,001 - $58,000………… |
7 |
Record number below |
$58,001 - $64,000………… |
8 |
Record number below |
More than $64,000……….. |
[ ] |
Terminate |
Don’t know/Refused ……... |
[ ] |
Terminate |
Answer to question 14: ____________ Answer to question 15: _______________
Accept respondent if he/she falls into one of the following categories:
___ Has 1 person in household (Q14), and answer to Q15 is 1.
___ Has 2 people in household (Q14), and answer to Q15 is 1 or 2.
___ Has 3 people in household (Q14), and answer to Q15 is 1, 2, or 3
___ Has 4 people in household (Q14), and answer to Q15 is 1, 2, 3, or 4
___ Has 5 people in household (Q14), and answer to Q15 is 1, 2, 3, 4, or 5.
___ Has 6 people in household (Q14), and answer to Q15 is 1, 2, 3, 4, 5, or 6.
___ Has 7 people in household (Q14), and answer to Q15 is 1, 2, 3, 4, 5, 6, or 7.
___ Has 8+ people in household (Q14), and answer to Q15 is 1, 2, 3, 4, 5, 6, 7, or 8.
[INTERVIEWER, RECORD WHICH CATEGORY RESPONDENT FALLS INTO]
What is your current age? [Do not read list]
Under 18………… |
[ ] |
Terminate |
18-34 …….……... |
[ ] |
Record |
35-50…….……… |
[ ] |
|
50+ ……... |
[ ] |
Terminate |
Are you of Hispanic or Latino origin?
No…………………. |
[ ] |
Continue |
Yes …….…….…… |
[ ] |
Continue |
What is your race? (READ LIST. ACCEPT MULTIPLE ANSWERS.)
American Indian or Alaska Native………... |
[ ] |
|
Asian ….…….……………………………. |
[ ] |
|
Black or African American …….……… |
[ ] |
|
Native Hawaiian or Other Pacific Islander.. |
[ ] |
|
White……………………………………… |
[ ] |
Recruit no more than 5* |
*Using questions 17 and 18, recruit no more than 5 white, non-Hispanic respondents for each group. The remaining 7 recruits can be any mix of other races, but should not all be of one racial or ethnic group. To the extent possible, these 7 should be split between Hispanics and African Americans.
What is the highest level of education you have completed? [Do not read list]
High school graduate or less.…….…. |
[ ] |
Recruit a mix |
Some college, vocational or technical school………………………………... |
[ ] |
|
College graduate…………… |
[ ] |
Recruit no more than 3 |
Post graduate education (e.g., Master’s degree, MBA, law degree, PhD) |
[ ] |
Terminate |
How comfortable would you be reading an information pamphlet that is written in English and telling someone what you think about it?
Very comfortable.…….…. |
[ ] |
Continue |
Somewhat comfortable……………………... |
[ ] |
Continue |
Somewhat uncomfortable…………… |
[ ] |
Terminate |
Very uncomfortable…………… |
[ ] |
Terminate |
Are you currently employed?
Yes, full-time……………... |
[ ] |
Recruit a mix of employed and not employed |
Yes, part-time……………… |
[ ] |
|
No………………………… |
[ ] |
Are you ……….
Married………………………... |
[ ] |
Recruit a mix |
Single, never married ………… |
[ ] |
|
Separated/divorced/widowed… |
[ ] |
Are you or your child participating in any one of the following nutrition programs? [select all that apply]
Food Stamp Program……….............................. |
[ ] |
Record |
Free- or Reduced-price School Lunch ………… |
[ ] |
|
Women, Infants, and Children Program (WIC)… |
[ ] |
Take a moment and think about your health. What is the biggest concern you have about your health and why?
Recruiter: After recording respondent’s answer, determine whether or not you feel this respondent would be useful in the group. Did she:
Give full and complete answer?
Answer enthusiastically?
Speaks understandable English/is comfortable with the English language
It is most important that respondent be articulate!! If not, terminate.
I would like to invite you to participate in a group discussion that will be held at our facility on (DATE) at (TIME). The group will last approximately 90 minutes. To help cover costs such as transportation to the focus group site and child care, you will receive [INSERT INCENTIVE] in cash at the end of the group session. Would you be willing to participate?
Yes……………( ) SCHEDULE No……………..( ) TERMINATE
I will call you to remind you of this appointment. However, if for some reason you are unable to attend, please call me at (TELEPHONE NUMBER) so that I can find a replacement for you. Thank You.
Respondent’s name: ___________________________________________
Address: ____________________________________________________
Telephone # (Home): __________________ (Work) _________________
Recruited by: _________________________________________________
File Type | application/msword |
File Title | USDA |
Author | taryn antigone |
Last Modified By | awhite |
File Modified | 2008-03-24 |
File Created | 2008-03-24 |