Form 1 Focus Group Screener

OMB Number: 0925-0590

Expiration Date: xx/xxxx

Screening Instrument: Women

National Children’s Study Messages and Materials

We are conducting research with women to talk about some health issues. We are not selling or promoting any product or service. If you qualify and complete the focus group, you will be paid $[Amount]. The focus group will be conducted in [city] and will last about 90 minutes. The focus group will be recorded and saved; however no one will know your name or contact information.

To see if you qualify to participate, I would like to ask you a few questions. Do you have a few minutes now? These questions will take less than five minutes to answer.

Please use the following language for termination of screening:

“Thank you very much for your time today. We are looking to recruit a wide variety of women to help with this study, and we have already recruited enough people with backgrounds similar to yours. Again, thank you for your interest.”

1. Are you a woman between the ages of 18 and 45?

( ) Yes Continue

( ) No Thank and Terminate

2. Which of the following age categories best describes you?

( ) Age 19-29 Continue

( ) Age 30 to 39 Continue

( ) Age 40 or older Continue

3. In the past 6 months have you participated in a market research study, focus group or interview, not including online surveys, where you were paid for your time and/or for providing your opinions?

( ) Yes Thank and Terminate

( ) No Continue

4. Are you or anyone in your home currently studying, working in, or retired from any of the following?

( ) Medical/health field (e.g., doctor, nurse) or public health Thank and Terminate

( ) Media outlet or field Thank and Terminate

( ) Market research, public relations, or advertising fields Thank and Terminate

( ) None of the above Continue

5. Are you currently pregnant, considering pregnancy, or the mother of at least one child 12 months or younger?

( ) Yes Continue

If yes, are you:

( ) Currently pregnant Recruit a mix

( ) Considering pregnancy Recruit a mix

( ) Mother of at least one child 12 months or younger Recruit a mix

( ) No Thank and Terminate

6. Are you comfortable reading and reviewing materials in English?

( ) Yes Continue

( ) No/Don’t know Thank and Terminate after Question 8

7. Which of the following categories best describes your level of education

( ) Less than high school Recruit into SC or less

( ) Some high school Recruit into SC or less

( ) Completed high school/GED Recruit into SC or less

( ) Some college/technical training/associate’s degree Recruit into SC or less

( ) Completed college/bachelor’s degree Recruit into college or more

( ) Graduate degree (master’s or higher) Recruit into college or more

Recruit a mix

8. Which of the following categories best describes your ethnic background?

( ) Hispanic or Latino

( ) Non-Hispanic or Non-Latino

( ) Intentionally withheld

9. Which of the following racial categories best describes your racial background?

( ) African American/Black Continue

( ) Caucasian/White Continue

( ) Asian Continue

( ) American Indian or Alaska Native Continue

( ) Native Hawaiian or other Pacific Islander ………………………………….. Continue

( ) Other Continue

( ) Intentionally withheld Continue

Recruit a mix

10. Which of the following categories best describes your total annual household income?

( ) Less than $15,000 Continue

( ) $15,001 to $30,000 Continue

( ) $30,001 to $40,000 Continue

( ) $40,001 to $60,000 Continue

( ) $60,001 to $75,000 Continue

( ) More than $75,000 Continue

( ) [Refuse—do not read out loud] Continue

[Recruit a mix. If participant refuses, record and continue.]

Are you willing to attend?

( ) Yes………………………………………………………………………..…………..Recruit

( ) No……………………………………………………………………..Thank and terminate

Name_________________________________________________________________

Address_______________________________________________________________

City/State/Zip___________________________________________________________

Day Number____________________ Cell/Other Number_______________________

Invitation

Thank you for answering my questions. I would like to tell you a little more about the focus group. The focus group will take place on [Date] at [Time] at our facility in [City, address]. It will last about 90 minutes. You will receive $[Amount] for participating. Some researchers may observe the focus group from behind a one way mirror. The focus group will also be audio taped, but your name will not be used in connection to the research or any reports that are written.

So that we can start and end on time, please plan to arrive about 15 minutes early to pick up your nametag and to have some refreshments. We are counting on your participation, so please be sure to contact us as soon as possible if something comes up and you can't attend. (GIVE YOUR NAME AND PHONE NUMBER.)

Also, do you wear glasses or use a hearing aid? If so, please remember to bring them. Some activities will involve reading and listening.

( ) Has hearing aid

( ) Has glasses

Before we hang up, let me confirm the contact information we have already collected so we can send you a confirmation letter with directions to our facility and give you a reminder call the day of the group.

YOUR NAME IS (read information)______________________________

YOUR HOME PHONE IS (read information)______________________

YOUR ADDRESS IS _(read information)___________________________________________

____________________________________________

YOUR WORK PHONE IS (read information)____________

YOUR CELL PHONE IS (read information) _________

YOUR E-MAIL IS (read information) _______________

Thanks again for your time and we'll see you at [date/time]!

^ Public reporting burden for this collection of information is estimated to average 5 minutes, 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.