Screener for Follow-up Assessment

Attachment 2a

Screener for

Follow-up Assessment of Matter of Balance Programs

F ollow-up Assessment of Matter of Balance Programs: Screener for

Questionnaire for OMB Submission

January 14, 2009

Prepared for the National Center on Injury Prevention and Control by:

Form Approved

OMB Control No. 0920-----

Expiration Date: ----------

Public reporting burden for this collection of information is estimated to average 3 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920------).

Interviewer’s Script

Section 0: Eligibility/Consent

E1: May I speak to (name of participant)?. STOP

If “no,”

Is there better time to reach (name of participant)? Thank you. I’ll call back at that time. STOP.

If “yes”,

To the correct respondent:

My name is (name) and I’m calling on behalf of the Centers for Disease Control and Prevention. We are conducting a survey of people who have taken Matter of Balance to better understand how the program affects a person’s health and wellbeing.

May I ask you some questions about your experience with Matter of Balance?

Your participation is voluntary. The survey will take about forty-five minutes. Your answers will be combined with answers from other people and will not be linked with your name in any reports of the results.

E3: Are you willing to take part in our survey?

If “no”

Attempt refusal conversion techniques before hanging up.

If “yes”,

Great, Thank you.

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