3 Interview Screener

OMB Number: 0925-0590

Expiration Date: xx/xxxx

Screening Instrument: Health Care Providers

National Children’s Study Messages and Materials

Hello, my name is ____________________with _____________, a market research firm. Today, we are talking with health care providers about a public health issue. We have a few brief questions and if you qualify and are interested, we will invite you to take part in an interview that will take place at a later date.

1Which, if any, of the following describe your specialty? [Read list]

( ) Obstetrics…….………………………………………...……………………..Recruit a mix

( ) Gynecology…………………………………………………………………...Recruit a mix

( ) Family Practice……………………………………………………………….Recruit a mix

( ) Internal medicine…………………………………………………………..…Recruit a mix

( ) Pediatrics…………………………………………………………………...…Recruit a mix

( ) Midwifery………………………………………………………………………Recruit a mix

( ) Public health nurse…………………………………………………………..Recruit a mix

( ) Other (______________) Note: If the “other” specialty frequently deals with women of a child-bearing age, they may be included. If not, thank and terminate.

1. What percent of your practice involves seeing female patients between the ages of 18 and 45?

( ) 50% or greater……………………………………………………………………….Recruit

( ) 50 % or less………………………………………………………….Thank and terminate

2. Are you board-certified or board-eligible in your specialty?

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

( ) No, not applicable to my field………………………………………………………Recruit

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

3. Do you work in a private practice?

( ) Yes………………………………………………………………….………….Recruit a mix

( ) No……………………………………………………………………….……..Recruit a mix

4. [Document gender, recruit a mix.]

5. [Assess ability to speak and understand English.]

Your interview will be held on ___________________ at ______________ AM/PM. It will last for approximately one hour. Because we know your time is valuable, at the end of the discussion we will pay you $XX for participating.

6. 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 interview. The interview will take place on [Date] at [Time] at our facility in [City, address]. It will last about 60 minutes. You will receive $[Amount] for participating. Some researchers may observe the interview from behind a one way mirror or by telephone. The discussion will also be audio taped, but your name will not be used in connection to the research or any reports that are written.

Are you OK with the arrangement? (pause to allow person to respond)

Yes or No? (record response)

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 have them on hand. 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 follow up information and give you a reminder call the day of the interview.

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 3 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.