Form Approved
OMB
Control No. 0920-0800
Expiration Date: 1/31/2012
SCREEN FOR LIFE GENERAL POPULATION (ages 45-75) FOCUS GROUP RESEARCH
2010
RECRUITMENT SCREENER
Group Date: Group Time: ______ ____________
Respondent Name: ______ _________ __
Address: ______ _________ ___
City: State (important) Zip: __
Day Phone: Evening Phone: _________ |
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 (0920-0800).
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. Today, we are working on a study for the Centers for Disease Control and Prevention -- or CDC -- to learn more about people’s attitudes and beliefs about health. I want to assure you that this is not a sales call. In fact, some of the people I talk with today will be invited to participate in another part of the study that will pay $60 for about one and a half hours of time to give opinions about information materials that may be used for an advertising program. May I ask you a few questions?
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:
1 Male [Recruit a mix; must have both in all groups.]
Female
2. For this study, we need to know your age. What is your age? [Put age here: _______]
Do not read. Fill in age respondent gives you. Then circle category it’s in.
1 Under 45 years old [Terminate]
2 45 - 49 years old (Continue; OK 1-2 only]
3 50 - 54 years old [Continue]
4 55 - 59 years old [Continue]
5 60 - 64 years old [Continue]
6 65 - 69 years old [Continue]
7 70 -75 years old [Continue, OK 1-2 only]
8 76 or older [Terminate]
3. Are you currently employed? [CONTINUE for all -- Recruit a mix]
1 No
2 Yes, part time
3 Yes, full time
(If yes...) What type of work do you do? ____________________________________
(Terminate health professionals; otherwise, information only)
4. Have you or your spouse ever worked or volunteered for any of the following types of organizations?
Doctor’s office, hospital, clinic, pharmaceutical or drug company
If yes:
Please find out what type(s) of paid or volunteer positions and whether position was held by respondent and/or spouse: ____________________________________________________________________________
[TERMINATE if prospective participant is obviously a health professional such as doctor or nurse. Otherwise, continue screening. If unsure, check with client before recruiting.]
Terminate if any of the following are mentioned:
Health department or community health agency
Marketing research, advertising, or public relations agency or department
Centers for Disease Control and Prevention (“C-D-C”) or the National Institutes of Health (“N-I-H”)
An organization that focuses on cancer such as the American Cancer Society or another cancer-related organization
5a. How would you describe your ethnicity? DO NOT READ OPTIONS
1 Hispanic or Latino/Latina [Skip to Q5b]
NOT Hispanic or Latino (Fill in here: ________________________________)
5b. How would you describe your race?
SELECT ONE OR MORE FROM OPTIONS 1-5. If person gives more than one answer or says “multiracial”, code as 6.
1 White [Recruit @4-5]
2 African American or Black [Recruit @4-5]
[For responses 3-5, OK to recruit up to 4]
Asian
American Indian or Alaska Native
5 Native Hawaiian or Other Pacific Islander
6 Multiracial: ____________________
6. 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 insurance plan or plans: __________________________
2 No [Continue]
3 Don’t know [Terminate]
7. When was your last routine check-up or physical? ______________
8. Have you ever been told by a doctor that you have [READ SLOWLY] any sort of bowel disease such as colitis, inflammatory bowel disease, Crohn’s disease, colon cancer, or polyps in the colon or rectum? POLYPS ARE SMALL GROWTHS IN THE COLON OR RECTUM.
1 Yes: Which of these have you been told you have? ___________________ [Terminate]
2 No [Continue]
3 Not sure/don’t know [Continue]
9A. Have you ever been diagnosed with any kind of cancer?
1 No [Continue; go to Q11]
2 Not sure/don’t know [Continue; go to Q11]
For “skin cancer” only, skip to Q8. For other cancers, ask:
If response is LESS than 5 years, terminate.
If response is MORE than 5 years, recruit up to 3 who otherwise qualify.
9B. [Read slowly…] Have you…OR your mother…father…brother…sister…or any of your
children ever had colon cancer?
1 Yes [Terminate]
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. Thinking about the doctor visits you have had over the last 5 years, have you been tested for:
1 Diabetes or “Sugar” Yes No
2 Heart problems Yes No
3 Colon cancer
Yes Continue
No Continue
Don’t know Continue
4 [Ask Females only] Breast cancer Yes No
5 [Ask Males only] Prostate cancer Yes No
Now I am going to ask you some questions to determine if you have had some particular medical tests. I am used to talking with people about these tests, and I hope that you will not feel uncomfortable about these questions.
11a. There is a test that checks for blood in your stool – this is a kit you use at home to collect one or more stool samples from the toilet, and put them on a card that you send back to the doctor or a lab to be checked.
Do you know what disease or condition this test is used to find?
Yes (List all):____________________________________________________________________
No
Don’t know
Have you ever been given a test kit to check for blood in your stool?
3 Yes If yes:
Did you complete the test and return the card to the lab or doctor?
1 No [Continue; go to 11b]
2 Don’t remember [Continue; go to 11b]
3 Yes If yes:
When was the last time you completed this test?
[Record answer____________________] Note:
If unknown, try to jog memory by asking: Approximately when? [Read]
1 Within 1 year or approximately a year ago [ASK Qs in BOX; then terminate]
2 More than a year ago, but less than 2 years ago [ASK Qs in BOX; then terminate]
IF PERSON TERMINATES HERE, ASK:
T2. I am going to read several reasons people say they did this test. For each reason, please tell me whether or not it applied to you the FIRST time you did the test. (Circle responses)
a. My doctor recommended it. YES, applied to me NO
b. My spouse or partner convinced me that it was important. YES, applied to me NO
c. A friend convinced me that it was important. YES, applied to me NO
d. I saw an ad recommending it. YES, applied to me NO
e. Any other reason? (If yes, ask for reason) _________________________________
T3. What was the #1 MOST important reason for you: ______________________________ T4. Have you ever had a colonoscopy. It is a test in which a long, flexible, lighted tube is inserted into your rectum. Typically you are given IV medication to relax and you must have someone else drive you home.?
YES NO DON’T REMEMBER
T5. Do you know what disease or condition a colonoscopy is used to find?
Yes (List all):________________________________________________________________ No Not sure
T7. If a relative or friend of yours asked you about whether they should be tested for colon cancer, what would you say to encourage him or her to get tested? ___________________________________________________________________________
THANK AND END |
3 At least 2 or more years ago [Continue with Q11b. below]
11b. Now I am going to ask you some questions about a medical test called a colonoscopy. During the colonoscopy a doctor inserts a flexible, lighted tube into your rectum to view the colon. For this test, typically you are given IV medication to relax and you must have someone else drive you home. Some people confuse this test with yet another test in which a tube is inserted through the mouth or the nose. That’s a different test.
Do you know what disease or condition a colonoscopy is used to find? That is the test that typically involves some medication. Afterwards, someone else must drive you home.
Yes (List all):________________________________________________________________
No
Don’t know
Do you recall whether you have ever had a colonoscopy? .
No [Continue; go to 11c]
2 Yes [Continue with Q right below about when colonoscopy was done]
3 Not sure [Continue with Q below about when completed to see if this
jogs person’s memory]
Approximately, when was the last time you had a colonoscopy?
[Record answer]________________________
If response is…
a. Within the last year [ASK Qs in BOX; then Terminate]
b. Within the last 2-3 years [ASK Qs in BOX; then Terminate]
c. Within the last 4-5 years [ASK Qs in BOX; then Terminate]
IF ANSWERS a, b, or c, ASK:
T7. I am going to read several reasons people say they had a colonoscopy. For each reason, please tell me whether or not it applied to you the FIRST time you had a colonoscopy. (Circle responses)
a. My doctor recommended it. YES, applied to me NO
b. My spouse or partner convinced me that it was important. YES, applied to me NO
c. A friend convinced me that it was important. YES, applied to me NO
d. I saw an ad recommending it. YES, applied to me NO
e. Another ad I saw recommended it. YES, applied to me NO
f. Any other reason? (If yes, ask for reason) _____________ ____________________
T8. What was the #1 MOST important reason for you: ______________________________
T9. If a relative or friend of yours asked you about whether they should be tested for colon cancer, what would you say to encourage him or her to go? ___________________________________________________________________________
THANK AND TERMINATE FOR THOSE WHO ANSWER a, b, or c. |
d. 5 or more years ago, but less than 10 years
[Terminate]
e. More than 10 years ago [Continue]
f. Don’t know/don’t remember If still unknown, try asking…Was it:
Within the last 2 years [Terminate; end]
Within the last 5 years [Terminate; end]
5 or more years ago, but less than 10 years [Terminate]
Longer than 10 years ago [Continue]
11c. You may have heard about a test called a “virtual colonoscopy” or “CT colonoscopy.” This test is
usually conducted in the radiology department of a hospital or other medical setting. For this test, you will be asked to lie on a table, and a thin tube is inserted into the rectum. Images of the large intestine are then taken with an MRI or a CT machine. The difference between the virtual colonoscopy and a colonoscopy is that the virtual colonoscopy does not require medication, and you are awake during the test. The test usually takes about 10 minutes.
Do you know what disease or condition a virtual colonoscopy is used to find? [Information Only]
Yes (List all):________________________________________________________________
No
Don’t know
Do you recall whether you have ever had a virtual colonoscopy? .
No [Continue; go to 11c]
2 Yes [Continue with Q right below about when virtual colonoscopy was done]
3 Not sure [Continue with Q below about when completed to see if this
jogs person’s memory]
Approximately, when was the last time you had a virtual colonoscopy?
[Record answer]________________________
If response is…
a. Within the last year [ASK Qs in BOX; then Terminate]
b. Within the last 2-3 years [ASK Qs in BOX; then Terminate]
c. Within the last 4-5 years [ASK Qs in BOX; then Terminate]
IF ANSWERS a, b, or c, ASK:
T7. I am going to read several reasons people say they had a virtual colonoscopy. For each reason, please tell me whether or not it applied to you the FIRST time you had a virtual colonoscopy. (Circle responses)
a. My doctor recommended it. YES, applied to me NO
b. My spouse or partner convinced me that it was important. YES, applied to me NO
c. A friend convinced me that it was important. YES, applied to me NO
d. I saw an ad recommending it. YES, applied to me NO
e. Another ad I saw recommended it. YES, applied to me NO
f. Any other reason? (If yes, ask for reason) _____________ ____________________
T8. What was the #1 MOST important reason for you: ______________________________
T9. If a relative or friend of yours asked you about whether they should be tested for colon cancer, what would you say to encourage him or her to go? ___________________________________________________________________________
THANK AND TERMINATE FOR THOSE WHO ANSWER a, b, or c. |
d. 5 or more years ago, but less than 10 years
[Terminate;]
e. Don’t know/don’t remember If still unknown, try asking…Was it:
Within the last 2 years [Terminate; end]
Within the last 5 years [Terminate; end]
5 or more years ago, but less than 10 years [Terminate]
11d. Now I’m going to ask you about a test called a sigmoidoscopy. During this test, a doctor inserts a flexible, lighted tube into your rectum to view the colon. The sigmoidoscopy looks at part of the colon and is usually done without medication in the doctor’s office. Do you know what disease or condition a sigmoidoscopy is used to find?
Yes (List all):________________________________________________________________
No
Don’t know
. Do you recall whether you have ever had a sigmoidoscopy?
1 No [Continue; go to 11d]
2 Yes [Continue; ask Q below about when test was done]
3 Not sure [Continue; ask Q below about when test might have
been to see if it jogs person’s memory]
Approximately, when was the last time you had a sigmoidoscopy?
Record answer: ____________________
For responses…
Within the last year [Terminate]
Within the last 2-3 years [Terminate]
Within the last 4-5 years [Terminate]
6 or more years ago, but less than 10 [Continue]
More than 10 years [Continue]
Don’t know….Try to jog person’s memory by asking: Approximately when?
[Read] Was it…
Within the last 2 years [Terminate]
Within the last 5 years [Terminate]
6 or more years ago, but less than 10 years [Continue]
More than 10 years ago [Continue]
11e. Have you ever had an x-ray test of your colon, for which you first were given an enema through your rectum and then x-rays of your colon were taken? This usually is called a “barium enema”, or “lower GI test.” [Note: If person volunteers that he/she has had a tube down his/her throat or swallowed “chalky stuff,” before an x-ray, this is not the same test. OK to continue if test did NOT involve an enema.]
2 Yes If yes, ask: When was the last time you completed this test?
Record answer:____________________
For responses…
Within the last year [Terminate]
Within the last 2-5 years [Terminate]
More than 6 years ago Continue
Don’t know If unknown, ask: Approximately when?
[Read] Was it…
Within the last 2 years [Terminate]
Within the last 3-5 years [Terminate]
More than 6 years ago [Continue ]
Thank you for answering all these medical questions. I have just a few more questions but these are not medical.
12. What is the last grade or year of school you completed?
1 Less than high school [Terminate]
2 Some high school (no more than 2; save screeners for people who terminate here but qualify otherwise.]
Recruit @half who answer 3 or 4
3 Completion of high school
4 Some college
5 Completion of college
Post-graduate degree
[No more than 2 with post graduate degree]
13. Is your total annual household income:
Below $60,000 [Recruit @6]
Above $60,000 [Recruit @6]
How many people live in your household? _______________
14.. When, if ever, was the last time you participated in a focus group?
Have never participated [Continue]
Within the last 6 months: What was the topic? _____________________________
Terminate if topic was cancer-related.
More than 6 months ago [Continue]
INVITATION:
The project I am working on includes several small groups of 8 or 10 people who will meet once for about one and a half hours to talk informally and give their opinions about some information that will be used in advertising. The discussion will be at our office which is easy to get to. You do not need to prepare in any way or have any special skills to participate, although there will be some brief reading involved. This truly is about your opinions and reactions to some information for advertising. Everyone who participates will receive $60.
We would like to invite you to participate in a group on [day/date/time]
____________________________________________________
Are you available to participate?
1 Yes [If yes, ask reading comfort question on next page; If OK, record
information on front of screener for confirmation]
2 No [Thank and end call.]
READING COMFORT:
I have one more question…As I mentioned, this part of the study will involve some reading. Some people have vision or reading difficulties that make them prefer to be considered for other studies we may do instead. Will you be able to read some brief materials or would you prefer to be contacted for another study?
____Reading is OK.
CONFIRMATION LETTER SHOULD REMIND PEOPLE:
to bring reading glasses to alert them that the group will involve reading materials.
that pagers and cell phones cannot be permitted during the group.
Group itself will take about one and a half, so total time commitment will be slightly longer… important to arrive at least 15 minutes early to check in.
that a place is specially reserved for them so it is very important to call if something comes up so that someone can be invited to take their place.
| File Type | application/msword |
| File Title | Draft, 2/24/10 |
| Author | D4700 |
| Last Modified By | arp5 |
| File Modified | 2010-06-29 |
| File Created | 2010-06-29 |