Form Approved
OMB No. 0920-0798
Exp: 01/31/2011
ATTACHMENT 1 – PRE-SCREENER
We are contacting you because you have expressed interest in participating in paid research studies.
We are conducting some paid telephone research studies about common public health issues facing Americans today. For this study, we are specifically looking for people whose medical prescriptions are covered or partially covered by an insurance plan of some sort.
The study will take 90 minutes and will be held over the phone. There are many time slots available in October. You will be paid $50 for participating in the 90-minute telephone study. Your opinions will be used to help inform the public about health.
No attempt will be made to sell any products or services to you as a result of your participation.
To be considered for this study, please reply to this email with answers to the questions below.
Name:
City and state of residence:
Phone and a good time to reach you:
Your Age:
Highest Level of Education you have finished:
Race/Ethnic Background:
1. Are you the birth parent, adoptive parent, or step-parent of any children?
2. If you currently have children living at home with you, what are their ages?
3. Do you have a weakened immune system or disease, such as severe asthma, that tends to lead to sniffles, coughing, or wheezing into a bacterial infection, such as pneumonia?
Public reporting burden of 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0798).
4. If you have any children living at home, do they have a weakened immune system or disease, such as severe asthma, that tends to lead to sniffles, coughing, or wheezing into a bacterial infection, such as pneumonia?
5. How would you describe the geographic area where you live? Is it a…
a. Rural area
b. Small city or town
c. Suburb
d. Large City
6. When you have a new prescription filled for yourself (or for your child/children) which of the following best describes how much you pay?
a. I (or another family member/partner) pay nothing, a health plan pays all of it
b. I (or another family member/partner) pay part of it; a health plan pays the rest
c. I (or another family member/partner) pay the entire cost of the medication
Based on your answers we may contact you to ask a few additional questions and to schedule all qualified applicants for the interviews.
Thank you for your interest, and I look forward to speaking with you.
Sincerely,
Robyn G. Raggio
Project Manager/Research Recruiting Specialist
Blarry House Research
Blarry House Research values your privacy. Our panel list is never shared with any third parties and you will never be solicited in any way as a result of participating in one of our studies. Panel members have either requested to be added to our database from our website or have participated in a study with us in the past.
If at any time you would like to be removed from our panel please do not reply to this email but rather send a request to [email protected] A real person (not a computer) will see your request and will remove you from our database. Please see our site for details about our privacy policy.
| File Type | application/msword |
| File Title | We are contacting you because you have expressed interest in participating in paid research studies |
| Author | Annaliese Furnas |
| Last Modified By | bmm1 |
| File Modified | 2009-12-10 |
| File Created | 2009-12-07 |