AttA2 - Prediscussion Info Sheet Latina

Pre-Discussion Information Sheet—Participant Version (Latinas)

Form Approved

OMB No. 0920-0800

Exp. Date 1/31/2012

Pre-Discussion Information Sheet

Public reporting burden for this collection of information is estimated to average 30 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)

Please write only your first name on this form.

1. What is your date of birth? (Month/Day/Year)

2. What is your highest education level completed?

• 6th Grade or less

• 7th – 8th Grade

• 9th – 11th Grade

• 12th Grade without a High School diploma

• 12th Grade with a High School diploma

• GED

• Some college

• Associate degree

• Completed college (4 year degree)

3. What is your employment status? (Check all that apply)

Full-time Part-time Presently not employed outside the home, looking for work Presently not employed outside the home, not looking for work

Student Laid Off On Strike Disabled

4. What do you do for a living? What is your occupation/profession?

5. How many televisions do you have in your home?

• 0

• 1

• 2

• More than 2

6. How often do you listen to the radio?

• Never or rarely

• 1-2 days a week

• 3-4 days a week

• 5-6 days a week

• Every day

7. Do you listen to the radio when you are________ (Check all that apply)?

• In the car

• At work

• At home

• Some other place

8. During what time of the day do you most often listen to the radio?

• In the mornings (5am-12pm)

• In the afternoons (12pm-6pm)

• In the evenings (7pm-12am)

9. On which days of the week are you most likely to listen to the radio? (Check all that apply)

Monday Tuesday Wednesday Thursday

Friday Saturday Sunday

10. Which of the following types of radio stations do you usually listen to? (Check all that apply)

• Talk Stations

• Music Stations

• AM

• FM

11. During the past 30 days, which of the following have you listened to at least 3 times a week? (Check all that apply)

Alternative	Gospel		Pop
Ambient	Hip Hop		Punk
African	Heavy Metal		Rap
Bluegrass	Hard Rock		Reggae
Blues		Instrumental		R & B
Caribbean		Jazz		Rock
Classical		Latin		Salsa
Christian		Musical		Trance
Country		New Age
Disco		Oldies
Folk		Opera

12. When you listen to the radio, which station or stations do you listen to most often?

Write in station dial location and name:

13. When you listen to the radio, how do you access the radio stations that you listen to?

• Using the Internet

• On a handheld device

• On a stand-alone radio

• Other: _______________

14. Please indicate below from which of the following sources do you usually get information about health services in your community and how often.

Television	Always	Sometimes	Rarely	Never
Radio	Always	Sometimes	Rarely	Never
Newspapers	Always	Sometimes	Rarely	Never
Magazines	Always	Sometimes	Rarely	Never
Internet	Always	Sometimes	Rarely	Never
Doctor visits	Always	Sometimes	Rarely	Never
Church or religious organizations	Always	Sometimes	Rarely	Never
Friends	Always	Sometimes	Rarely	Never
Family members	Always	Sometimes	Rarely	Never
Other:_________________	Always	Sometimes	Rarely	Never

15. Please indicate below if you read any of the following newspapers and how often.

	No	Yes, Weekend only	Yes, 2-3 days per week	Yes, 4-7 days per week
Ledger-Enquirer
USA Today
Creative Loafing
Atlanta Journal-Constitution
[Other local papers]
Other:___________________

16. For each question below (questions 16 through 23) please mark the box that best represents how you feel:

Question	1 (Not at all serious) (Not Likely)	2	3	4	5	6	7 (Very serious) (Very Likely)
How serious is breast cancer?							
How likely is it that you will get breast cancer?							
Breast cancer screening will keep me from dying from breast cancer.							
I am easily able to get screened for breast cancer.							
My family member or friend thinks breast cancer is a serious disease.							
My family member or friend thinks I am at risk for breast cancer.							
My family member or friend thinks breast cancer screening will prevent me from dying from breast cancer.							
My family member or friend thinks I am able to get screened to prevent me from dying from breast cancer.							

This is the end of our questions.

Thank you for your time.

Page 4 of 4