Form 1 survey

Appendix A – NCS Formative Research Recruiting Questionnaire

Automated Self-response methods for pregnancy follow-up

INTRO

Screener for the National Children’s Study – Self Response Methods Pretest

NAME____________________________ PHONE__________________________

RESPONDENT Number ____________________

I have to ask you some questions to determine whether you are eligible for our study. It will only take a few minutes.

IF NEEDED: Westat, a research company in Rockville, Maryland is conducting survey research for the National Institute of Child Health and Human Development to test questions for an upcoming national survey.

Q1. ASK ONLY IF NOT OBVIOUS: Are you male or female?

1. Male – TERMINATE AND THANK (“Based on the requirement of this study it looks like we can’t include you at this time. It is possible we will be calling you in the future for other studies.”)

2. Female

Q2. Which of the following age categories are you in?

1. Under 18 – TERMINATE AND THANK (“Based on the requirements of this study, it looks like we can’t include you at this time. It is possible we will be calling you in the future for other studies.”)

2. 18 – 24

3. 25 – 29

4. 30 – 34

5. 35 – 39

6. 40 – 44

7. 45 - 48

8. 49 and older – TERMINATE AND THANK (“Based on the requirements of this study, it looks like we can’t include you at this time. It is possible we will be calling you in the future for other studies.”)

INTERVIEWER: RECRUIT A MIX OF AGES.

Q3. These interviews will be taking place at (PLACEHOLDER - Westat’s headquarters, located on Research Boulevard in Rockville, Maryland.) Are you within driving or commuting distance of our location?

PROVIDE MORE INFO IF NEEDED: 1650 RESEARCH; NEAR THE CORNER OF RESEARCH AND GUDE DRIVE; 63 OR 54 BUS STOPS IN FRONT OF 1650; ETC.

1. Yes

2. No – TERMINATE AND THANK (“Based on the study design, our interviews are going to be conducted at Westat, so it looks like we can’t include you at this time.”)

Q4a. Have you ever used an automated telephone system? For example, when you call a bank or a retail store, sometimes you first interact with an automated system that gives different choices for directing your call. Have you ever used any kind of automated telephone system?

1. Yes

2. No  SKIP TO Q5a

Q4b. Have you ever used an automated phone system to do any of the following?

3. Request information or a service from a bank or retail store?

   1. Yes

   2. No

4. Place an order?

   1. Yes

   2. No

5. Respond to a survey?

   1. Yes

   2. No

6. Any other reason?

   1. Yes

   2. No

Q5a. Do you use the Internet at home or work?

7. At home only

8. At work only  SKIP TO Q6a

9. Both work and home

10. No, do not use the Internet at all  SKIP TO Q6a (IF OTHERWISE ELIGIBLE, THIS PERSON CAN ONLY PARTICIPATE IN THE IVR TESTING)

Q5b. Do you have an email account through your home Internet provider?

1. Yes

2. No  SKIP TO Q6a

Q5c. About how often do check your home email account?

1. At least once a day

2. Every 2-3 days

3. Once a week

4. Two or three times a month

5. Once a month or less often

Q6a. Do you have a cell phone for your personal use?

1. Yes

2. No  Skip to Q7

Q6b. Do you send and receive text messages on your cell phone?

1. Yes

2. No  Skip to Q7

Q6c. About how often do you text?

1. At least once a day

2. Every 2-3 days

3. Once a week

4. Two or three times a month

5. Once a month or less often

Q7. Are you of Hispanic or Latino Origin?

1. Yes

2. No

Q8. Are you…READ OPTIONS ALOUD

1. White

2. Black or African American

3. Asian

4. Native Hawaiian or Other Pacific Islander

5. American Indian or Alaska Native

Q9. What is the highest level of education you have completed?

1. 11^th grade or less

2. 12 years of school, no diploma

3. GED or high school graduate (diploma)

4. Some college or technical school

5. College or technical school graduate

6. Post-graduate

As I mentioned previously, we are interviewing people in the Rockville/Montgomery County area to help us evaluate some questions that are going to be part of a survey about women and pregnancy. I’m going to ask some questions to see if you are eligible to help with the survey

QA. Including yourself how many adults age 18 years and older live in your household.

|___|___|

NUMBER OF ADULTS

QB. How many children under 18 years of age live in your household.

|___|___|

NUMBER OF CHILDREN

TOTAL HOUSEHOLD SIZE QA + QB = |___|___|

END

You are eligible to help with this research project. As I mentioned earlier, we are interviewing people in the Rockville/Montgomery County area. Some women may view the questions as sensitive, for example 2 of our questions are about sexual activity. Are you interested in participating?

YES — Thank you so much for your willingness to help us. For taking part you will receive $50 upon completion of the interview. I’m going to set up a time for you to meet with someone from the study team. CONTINUE TO SCHEDULING ACTIVITIES

NO — Thank you for taking the time to talk with me today. Have a great (day / evening). END CALL.

[COMPLETE SCHEDULING ACTIVITIES THEN GO TO FINAL QUESTION]

FINAL QUESTION:

Before we hang up, can you tell me how you would like us to get in touch with you if we need to speak with you between now and your scheduled appointment?

1. Telephone  (recollect phone number): _______________________________

2. Email  (get email address): _______________________________________

3. Text  (collect phone number):______________________________________

4. Postal service mail  (get mailing address):

____________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thanks. If we need to get in touch with you, we’ll always try to reach you by phone first, and if necessary we’ll [(text you) / use the (email / mailing) address] you just provided as well. Thanks for your time today. Have a great (day/evening.)

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Public reporting burden for this collection of information is estimated to average 0.08 hours (5 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0590). Do not return the completed form to this address.