Form #1 Form #1 Screener

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Health IT Focus Group Recruiting Screener

INTRODUCTION. Hello, I’m calling from [RESEARCH FIRM]. We are assisting in a research study for the Agency for Healthcare Quality and Research. We are seeking people to participate in a focus group discussion that will gather opinions about issues related to healthcare. We are scheduling groups for [DATES]. It will last no more than two hours and participants will be paid $[AMOUNT] to show our appreciation for your time.

May I ask you a few questions to determine if you are eligible for this focus group? It should take no more than two minutes. Your name and other identifying information will not be shared with anyone not directly involved with this study.

Q1a. Have you participated in any type of focus group study, either for [RESEARCH FIRM] or another firm, within the past 6 months?

YES (NOT ELIGIBLE)

NO

Q1b. Have you worked in a health or medical field within the last five years? (e.g., Doctor’s office, hospital, health insurance company)

YES (NOT ELIGIBLE)

NO

Q2. When was the last time you visited any type of healthcare provider for your own care? (By healthcare providers, we mean medical doctors, nurses, or hospitals, but not dentists)

MORE THAN TWO YEARS AGO/BEFORE [MONTH/YEAR] (SKIP TO Q4)

WITHIN THE PAST TWO YEARS / SINCE [MONTH/YEAR]

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to respond to this questionnaire. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Q3. How many different healthcare providers have you visited for your own health since [MONTH/YEAR]? (Again, this includes medical doctors, nurses, or hospitals, but not dentists)

ONE

TWO

THREE OR MORE

Q4. Have you visited any type of healthcare provider for the care for a close family member since [MONTH/YEAR]? (By healthcare providers, we mean medical doctors, nurses, or hospitals, but not dentists)

YES

NO (SKIP TO BOX 1)

Q5. How many different healthcare providers have you visited for the care of a close family member since [MONTH/YEAR]? (Again, this includes medical doctors, nurses, or hospitals, but not dentists)

ONE

TWO

THREE OR MORE

BOX 1

IF NO VISITS TO A HEALTHCARE PROVIDER SINCE [MONTH/YEAR]

THEN NOT ELIGIBLE

OTHERWISE, CONTINUE

Q6. Are you managing any chronic health conditions, or assisting a close family member in the management of their chronic health condition?

YES – MY OWN CONDITION

YES – ASSISTING CLOSE FAMILY MEMBER

NO

Q7. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare or Medicaid? (This is about you, yourself. I will ask about your family member in a moment)

YES

NO (SKIP TO BOX 2)

Q8. What kind of healthcare coverage do you have? (SELECT ALL THAT APPLY)

HMO

MEDICARE

MEDICAID

OTHER (SPECIFY):___________________________________

DON’T KNOW

BOX 2

IF MADE HEALTHCARE VISITS FOR A CLOSE FAMILY MEMBER, ASK Q9

OTHERWISE SKIP TO Q11

Q9. Does the family member for whom you have visited a healthcare provider have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare or Medicaid?

YES

NO (SKIP TO Q11)

Q10. What kind of healthcare coverage does this family member have? (SELECT ALL THAT APPLY)

HMO

MEDICARE

MEDICAID

OTHER (SPECIFY) :___________________________________

DON’T KNOW

Q11. How often would you say that you use a computer for any purpose? Would this be….

Often

Now and then

Only rarely, or

Never (Q13)?

Q12. How comfortable would you say you are with computers? Would you say….

Very comfortable

Comfortable

Not too comfortable, or

Not at all comfortable

Q13. How much trust would you say you have in computers? Would you say….

A lot of trust

A fair amount of trust

Only a bit of trust, or

No trust at all?

I have just a few more questions.

Q14. Are you Hispanic or Latino/Latina?

YES

NO

Q15. Please select one or more of the following to indicate your race.

White

Black or African-American

Asian

American Indian or Alaska Native, or

Native Hawaiian or other Pacific Islander?

Q16. [IF NOT OBVIOUS, ASK] Are you male or female?

MALE

FEMALE

Q17. What is the highest level of education you completed?

LESS THAN HIGH SCHOOL

HIGH SCHOOL GRADUATE

SOME COLLEGE/VOC. ED

COLLEGE GRADUATE

ADVANCED DEGREE

Q18. What is your age? ___________________

BOX 3

CHECK RECRUITING TARGETS TO DETERMINE WHETHER THIS PERSON IS NEEDED

IF NOT, THANK AND TERMINATE

IF SO, CONTINUE

INVITATION TO PARTICIPATE: We would like to invite you to attend the focus group discussion with about 10 other people. It will be held at [PLACE] on [DAY AND DATE] at [TIME], and will last no more than 2 hours. Will you be attending?

YES

NO

Thank you for agreeing to participate and we look forward to seeing you at the focus group.

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