EXEMPLAR SCREENING FORM OMB#: 0925-0590
LOI2-QUEX-25 OMB Expiration Date: 06/30/11
[STUDY CENTER]
Screening Tool for Recruitment and Retention Network Focus Groups
[TARGET POPULATION] will be invited to participate in one of four focus group interviews.
Inclusion criteria will be: [EXEMPLAR CRITERIA: Adult, English-speaking men who are expectant fathers or new fathers (infant less that 1 year of age].
Potential participants will be screened prior to the consent process to verify eligibility.
[EXEMPLAR SCREENING QUESTIONS TO MEET INCLUSION CRITERIA]
1. Do you have any children?
If No: advise that they are not eligible and thank them for their time
If Yes: Continue to question 2
If expecting first child: Continue to question 3
2. What is/are the age(s) of your child(ren)?
If youngest child is older than 1 year: advise that they are not eligible at this time and thank them. Ask if it would be alright to keep their contact
information and potentially call them at a later date for additional groups.
If youngest child is less than 1 year of age: proceed to question 3
3. How old are you?
If less than 18 years of age: advise that they are not eligible and thank
them for their time
If 18 years of age or older: invite individual to participate
Review Consent Form with all eligible participants over the phone. Assign to Focus group.
Public reporting burden for this collection of information is estimated to average 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.
| File Type | application/msword |
| File Title | UMass Screening Tool for R and R Network Focus groups |
| Author | Celeste A. Lemay |
| Last Modified By | parkjenn |
| File Modified | 2011-03-25 |
| File Created | 2011-03-25 |