Form #1 Form #1 Screening form

S

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

creening Form

Parents of Young Children

SQPYC1: Do you have a child under 8 years of age?

• Yes (CONTINUE)

• No (THANK AND TERMINATE, SEE RESPONSE NUMBER 1)

SQPYC2: Have you ever given that child an over-the-counter medicine containing acetaminophen?

• Yes (CONTINUE)

• No (THANK AND TERMINATE, SEE RESPONSE NUMBER 2)

SQPYC3: Has your spouse or partner who shares parental responsibilities of that child who is 8 year of age or younger already taken part in this study?

• No (CONTINUE)

• Yes (THANK AND TERMINATE, SEE RESPONSE NUMBER 3)

TERMINATION RESPONSES

T1: Thank you for your interest. However, at this time we are only able to include parents of children who are younger than 8 years old. Thank you again.

T2: Because the purpose of this research study is to learn more about how parents give their children over-the-counter medications containing acetaminophen, we are not able to include parents who have never given their child an over-the-counter medicine. Thank you for your time.

T3: Because of the nature of the study, we are only able to include one parent from each family. Thank you for your time.

Public reporting burden for this collection of information is estimated to average 3 minutes per response, the estimated time required to complete the survey. 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. Form Approved: OMB Number 0935-XXXX  Exp. Date xx/xx/20xx. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Adults

SQA1: Have you used an over-the-counter medicine containing acetaminophen in the past 2 years?

• Yes (CONTINUE)

• No (THANK AND TERMINATE, SEE RESPONSE NUMBER 1)

TERMINATION RESPONSES

T1: Thank you for your interest. However, at this time we are only able to include people who have used an over-the-counter medicine containing acetaminophen in the past 2 years. Thank you again.

Adolescents (Teens)

SQT1: Are you between the ages of 13 to 20 years old?

• Yes (CONTINUE)

• No (THANK AND TERMINATE, SEE RESPONSE NUMBER 1)

SQT2: Have you ever heard of over-the-counter medicines? This is like Tylenol® or Advil® or things people might buy at the store and take on their own at home for a headache or other symptom.

• Yes (CONTINUE)

• No (THANK AND TERMINATE, SEE RESPONSE NUMBER 2)

SQTCESDC:

For the following questions, please respond with not at all, a little, some, or a lot.

DURING THE PAST WEEK…..
	Not at All	A Little	Some	A Lot
1. I was bothered by things that usually don’t bother me.	0	1	2	3
2. I did not fell like eating, I wasn’t very hungry.	0	1	2	3
3. I wasn’t able to feel happy even when my family or friends tried to help me feel better.	0	1	2	3
4. I felt like I was just as good as other kids.	3	2	1	0
5. I felt like I couldn’t pay attention to what I was doing.	0	1	2	3
6. I felt down and unhappy.	0	1	2	3
7. I felt like I was too tired to do things	0	1	2	3
8. I felt like something good was going to happen	3	2	1	0
9. I felt like things I did before didn’t work out right.	0	1	2	3
10. I felt scared.	0	1	2	3
11. I didn’t sleep as well as I usually sleep.	0	1	2	3
12. I was happy.	3	2	1	0
13. I was more quiet than usual.	0	1	2	3
14. I felt lonely, like I didn’t have any friends.	0	1	2	3
15. I felt like kids I know were not friendly or that they didn’t want to be with me.	0	1	2	3
16. I had a good time.	3	2	1	0
17. I felt like crying.	0	1	2	3
18. I felt sad.	0	1	2	3
19. I felt people didn’t like me.	0	1	2	3
20. It was hard to get started doing things.	0	1	2	3
COLUMN TOTALS
TOTAL SCORE ALL COLUMNS
If TOTAL SCORE ≥ 15 see Response T3

TERMINATION RESPONSES

T1: Thank you for your interest. However, at this time we are only able to include adolescents between the ages of 13 and 20 years old. Thank you again.

T2: Because the purpose of this research study is to learn more about adolescents’ knowledge of over-the counter medications, we are not able to include adolescents who have never heard of over-the-counter medicines. Thank you for your time.

T3: Your responses to these questions indicate that you may be feeling sad right now. This may not be a good time for you to talk with us. May I speak with your mother or father? I would like for you to stay on the line too or listen as well. With parent or guardian {Teen’s name} is feeling sad. It is may be good to talk with a health professional about these feelings. Here’s a number you can call to speak with someone about how {Teen’s name} is feeling. We will also send you some materials with more resources on how you may seek help in the mail.

Physicians

SQDR1: Are you a Family Medicine or General Internist physician?

• Yes (CONTINUE)

• No (THANK AND TERMINATE, SEE RESPONSE NUMBER 1)

SQDR2: Are you currently participating in a fellowship or residency training program?

• Yes (CONTINUE)

• No (THANK AND TERMINATE, SEE RESPONSE NUMBER 2)

SQDR3: Do you have an active Texas medical license?

• Yes (CONTINUE)

• No (THANK AND TERMINATE, SEE RESPONSE NUMBER 2)

SQDR4: Do you devote 50% or more of your professional time to clinical practice?

• Yes (CONTINUE)

• No (THANK AND TERMINATE, SEE RESPONSE NUMBER 3)

TERMINATION RESPONSES

T1: Thank you for your interest. However, at this time we are only able to include Family Medicine or General Internist physicians. Thank you again.

T2: Thank you for your interest. However, at this time we are unable to include fellow, residents, or trainees. Thank you again.

T3: Because the purpose of this research study is to learn more about how physicians interact with their patients regarding use of acetaminophen, we are not able to include physicians who are not in clinical practice. Thank you for your time.

T4: Because the purpose of this research study is to learn more about how physicians interact with their patients regarding use of acetaminophen, we are not able to include physicians who are not in clinical practice at least 50% time. Thank you for your time.

Pharmacists

SQRX1: Are you a PharmD with a pharmacy licensure in the state of Texas?

• Yes (CONTINUE)

• No (THANK AND TERMINATE, SEE RESPONSE NUMBER 1)

SQRX2: Do you devote 50% or more of your professional time to community pharmacy?

• Yes (CONTINUE)

• No (THANK AND TERMINATE, SEE RESPONSE NUMBER 2)

TERMINATION RESPONSES

T1: Thank you for your interest. However, at this time we are only able to include PharmD’s licensed in the state of Texas. Thank you again.

T2: Because the purpose of this research study is to learn more about how pharmacists interact with patients regarding use of acetaminophen, we are unable to include pharmacists who do not practice in the community setting. Thank you for your time.