Form 4 Screening Form

ATTACHMENT 8:

Screening Form

Form Approved

OMB No. 0920-xxxx

Exp. xx/xx/xxxx

Study Title: “People Living with Lung Cancer”

Screening Form

INSTRUCTIONS TO INTERVIEWER:

Use the contact information provided in the CONTACT FORM to place the call.

Screener:

Hello, my name is ___________________ and I work for [Local Clinical Site]. I am working on behalf of the U.S. Centers for Disease Control and Prevention, in collaboration with a research organization called RTI Intentional, to conduct interviews with people living with lung cancer. The purpose of these interviews is to understand experiences during diagnosis and treatment, as well as to hear about the everyday challenges of living with lung cancer. The findings from this study will help CDC develop programs that address the needs of individuals with lung cancer.

I believe that a member of your care team informed you about participating in this study and asked you if it would be okay for us to contact you. We are conducting 1-hour telephone interviews with people living with lung cancer and you would receive $75. We also request that you let us tape record the interview and to allow a representative from CDC to listen to the interview. However, your name or any other identifying information would not be included on or be a part of any reports developed from these interviews.

1. Do you have any questions about the study? ___________________________________________

2. Would you be interested in participating in this study?

Yes		 CONTINUE
No		 THANK YOU

Public reporting burden of this collection of information is estimated to average 10 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)

Great, I need to ask you a few questions first.

Ask screening questions 1-4 for each individual:

If NOT ELIGIBLE for any of these questions, discontinue screening.

Thank you for your interest. Unfortunately, you do not meet all the criteria for participation in this particular study.

3. What year were you born? _____ _____ _____ _____

Age greater than 29 or less than 81		 CONTINUE	For 2009: Any year between 1929 and 1979
Other		 NOT ELIGIBLE

4. When were you first diagnosed with lung cancer?

(Record year and, if respondent knows, month)

MONTH	YEAR

Check for Eligibility

Greater than or = to 6 months		 CONTINUE
Less than 6 months		 NOT ELIGIBLE

5. Are you covered by any kind of health insurance or some other kind of health care plan that covers routine doctor visits, preventive health care, and medical treatments?

Yes		 CONTINUE
No		 THANK YOU

What is the name of your plan? _________________________

6. Do you think you would be able to participate in a 1-hour telephone interview in either one or two sessions?

Yes		CONTINUE
No		DETERMINE WHAT THEY FEEL THEY WOULD BE ABLE TO DO AND HOLD

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

Smoking Status Questions

7. We’re interested in interviewing a variety of people with lung cancer who have different risk factors, including ones from smoking. Which of the following statements best describes your history of smoking? I am going to read each statement and then you can tell me which best describes you.

I have never smoked or not smoked more than 100 cigarettes, 25 cigars, or 25 pipes in my life		Classify as Never Smoked
I quit smoking more than 5 years ago		Classify as Former Smoker
I quit smoking within the last 5 years, but before I was diagnosed with lung cancer		Classify as Recent Quitter NOT ELIGIBLE
I quit smoking when I learned I had lung cancer		Classify as Smoker
I still smoke or smoke occasionally		Classify as Smoker

If NOT ELIGIBLE:

Thank you for your interest. Right now, we have several individuals of similar age and background who have responded. We are going to have to review your and others’ information before scheduling any interviews. After we review the information, we may call you back about participating.

Box 1: RECORD SELF-REPORTED SMOKING STATUS

Smoker 

Recent  Quitter

Former  Smoker

Never  Smoked

If they fit a smoking history category in which the required set of interview has been completed, please respond:

Thank you for your interest. Right now, we have several individuals of similar age and background who have responded. We are going to have to review your information along with information from others before scheduling any interviews. We will contact you in the next 2 weeks about participating

Otherwise, record information and let them know that you will pass their information to another individual who will call about setting up a time for an interview. RECORD INFORMATION ON ATTACHED FORM.

Continue to Contact Information Update

Contact Information Update

NAME:

ADDRESS:

CITY:

ZIP:

Should I need to call you back, what is the best time to reach you? What is the best telephone number to reach you at that time? If you do not answer, may we leave a private message at that number?

BEST TIME TO BE REACHED:

BEST PHONE NUMBER:

OK TO LEAVE A MESSAGE: Y / N

Is there another time and number we can try if we miss you?

ALTERNATE PHONE NUMBER: __

OK TO LEAVE A MESSAGE: Y / N

Your participation in this study is very important. If for some reason you will not be able to take part in this study, please let us know right away. You can call us anytime at 1‑866-RTI-1958-Ext 27068. If we are not here, please leave a message. Thank you.

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