0990-0281 Focus Group and Interview recruitment Screener

Form Approved

OMB No. 0990-0281

Exp. Date XX/XX/XX12

Focus Group and Interview Recruitment Screener

Interviewer: _________________________________ Date: _________________________________ Letter sent: _________________________________ Reconfirmation Call: ___________________________
HP Web Site Focus Groups Segmentation Groups Group 1 _____ [State Level] Group 2 _____ [State Level] Group 3 _____ [Local Level] Group 4 _____ [Local Level] Group 5 _____ [Community Based] Group 6 _____ [Community Based]	HP Web Site Interviews Segmentation Groups Group 1 _____ [State Level] Group 2 _____ [Local Level] Group 3 _____ [Community Based]

OMB BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0281. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

IQ Solutions Inc.

ODPHP Healthy People Web Site

Focus Group and Interview Recruitment Screener

CALL FROM LIST OF HEALTH PROFESSIONALS SEGMENTED BY LEVEL OF ORGANIZATION, STATE, CITY, URBANICITY AND TYPE OF ORGANIZATION.

Hello, I’m __________ with __________________, an independent research firm. We are conducting a project to better understand how health professionals use web based health resources and their interest in a web based community health planning tool. Would you be interested in potentially participating in a telephone discussion on this topic?

___ Yes. (Continue)

___ No. (Thank and terminate call)

I received your name from a federal agency that works with health professionals. I would like to ask you a few questions and review some information that I already have collected on your organization.

1. I have noted that you work for (name of organization) ___________________________. Is this true?

_____ Yes. (continue to Q2)

_____ No. (Thank and terminate call)

2. I have noted that this organization is a:

_____ State Level organization (responsible for statewide activities/planning)

_____ Local level organization (funded by State, working at local level)

_____ Community based organization (works at community level, not affiliated with State Health Department).

Is this true?

_____ Yes. (continue to Q3)

_____ No. (How would you categorize your organization? __________________)

(Recategorize according to respondent and determine need for that segmentation group).

3. How would you categorize the geographic area in which your primary target audience resides:

____ City

____ Suburban

____ Rural

____ Mix

4. What region of the country do you work in:

____ East Coast

____ Midwest

____ South

____ West Coast

5. What type of work do you do:

____ Program Planning

____ Direct Services

____ Health Education

____ School Based

____ Special Population Based

____ Other, (Please specify ________________________________)

6. Do you have access to the Internet at your place of employment?

____ Yes

____ No (Thank and terminate call.)

On selection sheet, note availability of appropriate slot for each screening respondent. If availability exists, proceed to invite respondent to participate in either a focus group or an interview:

[INVITE TO FOCUS GROUP]

Thank you for answering all of my questions. As I said earlier, we are talking to health professionals about their use of Web based health information for program planning and to get their reaction to a new Healthy People 2020 web site. We would like to hear your views. In order to hear them first-hand, we are holding a telephone/online focus group on [DATE] at [TIME]. The focus group will last about 2 hours and will be both fun and informative. You will receive a payment of $75.00 for your participation. This is an important project, and we hope that you will be part of it. May we schedule you for a focus group?

[INVITE TO INTERVIEW]

Thank you for answering all of my questions. As I said earlier, we are talking to health professionals about their use of Web based health information for program planning and to get their reaction to a new Healthy People 2020 web site. We would like to hear your views. In order to hear them first-hand, we are holding a telephone/online interview on [DATE] at [TIME]. The interview will last about 1 hour and will be both fun and informative. You will receive a payment of $50.00 for your participation. This is an important project, and we hope that you will be part of it. May we schedule you for an interview?

Invited for Focus Group Invited for Interview

NAME: _________________________________________________

ORGANIZATION: ____________________________________________

ADDRESS: _________________________________________________

CITY: _________________________________________________

ZIP CODE: _________________________________________________

PHONE: (DAY) _____________________________________

(FAX) _____________________________________

(EMAIL) _____________________________________

Interviewer: ____________________

Supervisor Confirm: ____________________

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