ATTACHMENT C:
HEALTH CARE CONSUMER SCREENER FORM
Form Approved
OMB No. 0920-XXXX
Expiration Date: XX/XX/XXXX
ealth Care Consumer Screener Form
Screener
Preventive Health Services among Smokers
FACILITY TO DO THE SCREENING.
Ask to speak to an adult male or female living in the household:
Hello, my name is I’m with , a local opinion research company. We are working on a project that is sponsored by the U.S. Centers for Disease Control and Prevention--or CDC--which is a part of the Department of Health and Human Services. We are interested in learning more about people’s experiences with screening tests and their health care. We are particularly interested in talking to smokers, and I want to assure you that we are not from a tobacco company or a company that sells quit smoking aids. We will be holding discussion groups of about 9 people and we would like you to be in one of them. The discussion will last approximately two hours. Would you mind if I ask you a few questions in order to see if you are eligible to be in one of the groups?
Yes – [Continue]
No – [Thank and end call.]
[NOTE: Participants must speak English very clearly. Please listen carefully to make sure that anyone recruited can speak clearly and loudly enough to participate fully in a group discussion in English.]
1. Record respondent gender:
[Ask gender if you are unsure].
[NOTE: GROUPS WILL BE SEGMENTED BY GENDER]
Male
Female
2. Which of the following age categories includes you? Are you...
1 Under 40 years old [Thank and Terminate]
2 40 - 50 years old [Continue]
3 51-60 years old [Continue]
4 61 – 70 [Continue]
5 71 –older [Thank and Terminate]
[RECRUIT A MIX OF AGES]
Public
reporting burden of this collection of information is estimated to
average 2 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 Reports Clearance Officer; 1600 Clifton Road NE,
MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)
3. Do you now smoke cigarettes every day, some days or not at all?
1 Every day: [Continue]
2 Some days [Thank and Terminate]
3 Not at all [Thank and Terminate]
4. How many cigarettes do you smoke each day?
[NOTE: There are typically 20 cigarettes in a pack.]
1 Less than a pack a day [Thank and Terminate]
2 Approximately 1 pack a day = 1.0 pack/day
3 More than 1 pack a day but less than 2 packs a day = 1.5 pack/day
4 Approximately 2 packs a day = 2.0 pack/day
5 More than 2 packs a day = 2.5 pack/day
4a. How many years have you been smoking?
_____ YEARS
Multiply packs times years.
_______ PACKS X _____ YEARS = ________ PACK YEARS
If PACK YEARS greater than OR EQUAL TO 20, keep. If less than 20, terminate.
5. Have you or your spouse ever worked for any of the following types of organizations?
Doctor’s office, hospital, clinic, pharmaceutical or drug company [Terminate]
Health department or community health agency [Terminate]
Tobacco or cigarette company [Terminate]
Marketing, advertising or public relations agency or department [Terminate]
Health organization, such as Arthritis Foundation,
American Cancer Society, or public health department [Terminate]
6. Are Hispanic/Latino?
a) Yes
b) No
7. How would you describe your race?
[DO NOT READ OPTIONS. OK if person gives more than one response.]
1 White [Continue]
2 Black or African American [Continue]
3 Native Hawaiian or Other Pacific Islander [Continue]
4 Asian [Continue]
5 American Indian or Alaska Native [Continue]
[Recruit at least 3 but no more than 6 from categories 2-5.]
8. Do you have any kind of health insurance to pay for routine health care?
1 Yes [Continue]
If yes: What is the name of your plan?____________________
2 No [Thank and Terminate]
3 Don’t know [Thank and Terminate]
[ATTEMPT TO RECRUIT A MIX OF DIFFERENT PLANS]
9. Has anyone in your immediate family, such as your mother, father, brother, sister, or child, ever had cancer?
1 Yes [Continue screening and hold]
Who? __________________________________
What kind? _____________________________
When were they diagnosed? ________________
2 No [Continue]
3 Not sure/don’t know [Continue]
[Note: OK if more distant blood relative, such as uncle, aunt, grandparent, cousin, etc.]
10. Have you ever been diagnosed with any kind of cancer?
1 No [Continue; go to Q8]
2 Not sure/don’t know [Continue; go to Q8]
3 Yes
If “skin cancer” only, ask: Was it melanoma or another kind of skin cancer? _________________.
If “don’t know,” “another kind”, “basal” cell or “squamous” cell carcinoma [Continue]
If “melanoma” skin cancer and all other types of cancer.
[Thank and Terminate]
11. Have you ever been told by a doctor that you have [READ SLOWLY] any sort of major lung conditions, such as chronic obstructive pulmonary disease (or COPD), or emphysema?
1 Yes: Which one/s: ________________ [Thank and Terminate]
2 No [Continue]
3 Not sure/don’t know [Continue]
12. When, if ever, was the last time you participated in a market research study or focus group in person (not over the telephone)?
Have never participated [Continue]
Participated within the last 6 months: [Continue screening and hold]
What was the topic?: _____________________________
3 Participated more than 6 months ago [Continue]
13. When was the last time you saw a doctor about your health?
___________ Within the last year [Continue]
__________ Within the last two years [Continue]
___________ More than 2 years ago [Terminate]
14. When was the last time you had a routine check-up or physical? __________ [Information only]
15. Thinking about the doctor visits you have had over the last 5 years, have you been tested for:
Diabetes or “Sugar” 1 Yes 2 No [Information Only]
Cholesterol levels in your blood 1 Yes 2 No [Information Only]
Heart problems 1 Yes 2 No [Information Only]
Colon cancer 1 Yes 2 No [Information Only]
Lung cancer 1 Yes 2 No [Information Only]
[Ask Females only] Breast cancer 1 Yes 2 No [Information Only]
[Ask Males only] Prostate cancer 1 Yes 2 No [Information Only]
Now, just so that we have people with a broad range of experiences can you tell me:
16. What is the last grade or year of school you completed?
1 Less than high school [Thank and Terminate]
2 Some high school [Thank and Terminate]
3 Completion of high school
3 Some college
4 Completion of college
5 Post-graduate degree [No more than 2]
17. Please stop me when I read the range that includes your total annual household income before taxes.
Less than or equal to $ 35,000
More than $35,000 and less than or equal to $ 70, 000
More than $70,000
[ATTEMPT TO RECRUIT A MIX]
INVITATION:
The project I am working on includes several small groups of approximately 9 people who will meet once for about two hours to talk informally about your experiences with doctors and health tests. The discussion will be at our office which is easy to get to. You do not need any special skills to participate. You would receive $75 for your participation. A light meal/refreshments [as appropriate for time of group] will be served.
We would like to invite you to participate in a group on [day/date/time]
________________________________
Would you be available to participate?
1 Yes [Continue]
2 No [Thank and end call.]
Please note that there is a small possibility that some of the people who are invited may not be needed, but that cannot be determined until the night of the group. If this happens, everyone who has arrived on time will be paid, even if you are not asked to stay for the discussion. We thank everyone for understanding this possibility.
Text – Terminate: Thank you, but we have enough people that fit your category.
| File Type | application/msword |
| File Title | Form Approved |
| Author | jkdoto |
| Last Modified By | tfs4 |
| File Modified | 2008-10-29 |
| File Created | 2008-10-29 |