Form No number No number Focus Group Screener

ATTACHMENT 3

Focus Group Screener

Form Approved

OMB No. 0920-XXXX

Exp. Date ­­­­xx/xx/20xx

Focus Group Screener –Audience Analysis of Environmental Health Issues

Hello, I’m _______________ with _____________________, an independent consumer research firm. We are not selling or promoting any product or service. We are conducting a focus group on people’s attitudes about global warming and climate change. Everyone who participates in these discussions will receive $75.00. I would like to ask you some questions to see if you qualify for one of the discussion groups. These questions will only take a few moments to answer. The groups will be held at [times] on [date] at [location] and will last about two hours. Refreshments will be served. Do you have time now to answer a few questions?

Recruit 12 to seat 9 respondents in the room

NOTE: Use the following language to “terminate” call throughout screening process:

“Thank you for taking the time to answer our questions. Unfortunately, the category you fall into is currently full. If it should open back up, may we call you back?”

1. Are you currently a resident of Santa Rosa, California?

( ) Yes Continue

( ) No Terminate

2. I will read you a list of series of activities that people sometimes engage in. For each activity, please tell if you currently do this activity and if you started this do this activity within the last 18 months. PLEASE tell me if you have started one these behaviors within the last 18 months. (MUST HAVE STARTED ONE OF THESE ACTIVITIES IN THE LAST 18 MONTHS).

Public reporting burden for this collection of information is estimated to average 5 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: Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

	Current Activity		Started in the last 18 months
	Yes	No	Yes	No
Buy environmentally friendly products
Buy energy-efficient appliances/insulation
Buy products made from recycled paper/plastic
Use less gas by driving less or getting a more fuel-efficient car
Remind others to be environmentally conscious
Use less energy at home (lights, AC, heat)
Punish companies with bad environmental records by not buying their products
Use a reusable shopping bags when grocery shopping
Buy organic food
Vote for candidates with the best environmental records
Recycle at home

3. Using a 5-point scale, where 1 = strongly disagree and 5=strongly agree, please tell me how much you agree or disagree with the following statement: (MUST GIVE RATING OF 3 OR HIGHER ON THIS QUESTION TO CONTINUE)

Strongly Strongly

Disagree Agree

Global warming is a very serious problem. 1 2 3 4 5

4. Have you EVER done one of the following activities? (RECRUIT A MINIMUM OF 4 RESPONDENTS WHO HAVE DONE ONE OR MORE OF THESE ACTIVITIES)

	YES	NO
Written or called any politician at state, local, or national level
Attended a public meeting on town or school affairs
Served on a committee for a local organization
Written a letter to the editor of a newspaper, magazine or called a radio or TV show to express an opinion
Served as an officer of a club or organization

5. Have you or anyone in your home worked in or retired from any of the following

industries? (Read and record response)

( ) Marketing or public relations Terminate

( ) Advertising Terminate

( ) Market research Terminate

( ) None of the above Continue

6. Have you participated in a focus group study within the last 6 months?

(Record response)

( ) Yes Terminate

( ) No Continue

DEMOGRAPHICS

7. GENDER

Males ______

Females _____

8. Which of the following best describes your age?

( ) 18-45 Continue

( ) 46-60 Continue

( ) 60 or older Continue

9. Which of the following best describes your education?

( ) Less than high school degree Continue

( ) High school degree Continue

( ) Some College Continue

( ) College degree Continue

( ) Graduate degree Continue

10. Employment Status

NAME______________________________

HOME PHONE______________________

WORK PHONE____________CELL PHONE _________