AttE2 - Recruitment Screener Latina

Focus Group (LATINAs)

eligibility Screener

screened and unscreened

Form Approved

OMB No. 0920-0800

Exp. Date 1/31/2012

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: CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0800)

Hello. My name is ____________ and I am working with ICF Macro, a consulting firm in Atlanta, Georgia and the Centers for Disease Control and Prevention (CDC) to learn women’s thoughts about health, breast cancer, screening and viable messages to educate women about breast cancer and increase screening among women who may qualify for free breast cancer screening.

We are asking 6 to 10 ladies to get together and talk about these ideas and messages. The discussion will last about 2 hours and 20 minutes, and happen only once. We will not ask you any questions about your own health status or personal health issues.

If you participate in the group, you will receive $50.00 cash in appreciation of your time. We will also serve a meal prior to the discussion. Do you think that you might be interested in participating in this type of discussion?

• Yes (Continue with screener.)

• No (Thank person for his/her time and end conversation.)

Would you mind if I ask you a few questions in order to determine whether or not you meet the eligibility requirements to participate in the discussion group?

• Yes (Continue with screener.)

• No (Thank person for his/her time and end conversation.)

NOTE TO RECRUITER: Please continue through all questions before letting individuals know that they cannot be invited to participate at this time based on at least one of the responses they provided.

Record and Keep all Screened Data

1. Record gender

• Male (Terminate at end.)

• Female

2. Are you Hispanic/Latina?

• Yes

• No

3. How do you describe your race? You may choose more than one race.

• Black or African American

• White (Terminate at end.)

• American Indian or Alaska Native (Terminate at end.)

• Asian (Terminate at end.)

• Native Hawaiian or Other Pacific Islander (Terminate at end.)

RECRUITER: If an individual self-identifies as Hispanic/Latina and any other race they remain eligible for the groups.

RECRUITER: We must determine your eligibility in the Breast and Cervical Cancer Program (BCCP). To be eligible for enrollment in the BCCP and receive federally-funded breast screening:

• The woman is within the age requirements recommended breast cancer screening.

• The woman is at or below 200% of the Federal poverty guidelines.

• The woman is uninsured.

4. Record age: _________________________

• What is your date of birth? (Month/Year)

RECRUITER: Record which age group they belong to:

• 39 and under (Terminate at end.)

• 40-49 (Recruit to 40-49 groups.)

• 50-64 (Recruit to 50-64 groups.)

• 65 and older (Terminate at end.)

5. How many immediate family members including you live in your house?

[Record # of people]

6. What is your household income per month before taxes?

RECRUITER: If the woman hesitates, ask her if she thinks it is more than or less than the amount you read next to the family size she just told you.

Read the dollar figure next to the correct Family Size the person just told you.

For family of 1, read $1,497 per month For family of 2, read $2,020 per month For family of 3, read $2,543 per month For family of 4, read $3,067 per month For family of 5, read $3,590 per month For family of 6, read $4,113 per month For family of 7, read $4,637 per month For family of 8, read $5,160 per month

More [Terminate at end] More [Terminate at end] More [Terminate at end] More [Terminate at end] More [Terminate at end] More [Terminate at end] More [Terminate at end] More [Terminate at end]

Less [Continue] Less [Continue] Less [Continue] Less [Continue] Less [Continue] Less [Continue] Less [Continue] Less [Continue]

7. Do you have health insurance coverage (includes Medicaid)?

• Yes (Terminate at end.)

• No

8. Have you had a mammogram in the last 3 years?

• Yes (Go to question 9.)

• No (Recruit to UNSCREENED Focus Groups – Go to question 10.)

9. Have you had a mammogram in the last 24 months (or 2 years)?

• Yes (Recruit to SCREENED Focus Groups – Go to question 10.)

• No (Terminate at end.)

10. Have you ever been diagnosed with breast cancer or ANY form of cancer?

• Yes (Terminate at end.)

• No

11. What is your home zip code? ________________________

• Is on the list of zip codes from which to recruit

• Is not on the list of zip codes from which to recruit (Terminate at end.)

12. Do you have any family members who have been recruited for this study?

• Yes (Terminate at end.)

• No

13. Are you willing to participate in a discussion to offer your thoughts about materials and messages to increase breast cancer screening in your community?

• Yes

• No (Terminate at end.)

TERMINATION SCRIPT: “We appreciate your willingness to answer each of the questions. Unfortunately, one of your answers does not meet our requirements for participation in the focus group. Thank you for your time.”

14. You are eligible to participate in the group. Are you still interested in participating?

• Yes

• No (Thank person for her time, terminate and end the conversation.)

I’m glad that you will be able to join us! The discussion group will last about an hour and a half. It will be held at [INSERT LOCATION in Charlotte or Raleigh, North Carolina]. The group in which we would like you to participate is scheduled for:

SCREENED
Place (Age Group)	Date	Group Number	Time
TBD (40-49)	TBD	Group 1	TBD
TBD (50-64)	TBD	Group 2	TBD
UNSCREENED
TBD (40-49)	TBD	Group 3	TBD
TBD (50-64)	TBD	Group 4	TBD

15. Does this date and time work for you?

• Yes

• No (Thank person for her time, terminate and end the conversation.)

[GET OTHER AVAILABLE TIMES THAT MIGHT WORK.]

In addition to the $50.00 you will receive for participating in the group, we will also conduct an Early Bird Raffle. If you arrive for the group at least 15 minutes early (before the group is scheduled to begin), you will be entered into the raffle. The drawing will take place at the beginning of the group, and the winner will receive an extra $25.00, so we encourage you to get there as early as possible! Do not forget that we will serve you a light meal prior to the discussion.

We would also like to be able to send you a reminder before the group. Can you please confirm your name, address, phone number, and e-mail?

Name:
Mailing Address:
Home Telephone:		Pager:
Work Telephone:		Cell Phone:
E-Mail:

Also, please contact [NAME] at [PHONE NUMBER] if your plans change so that we may invite someone from the waiting list to attend instead. Otherwise, we’ll look forward to seeing you on [Month/Day/Year] at [Time].

RECRUITER: (Please record the location where you screened this woman: )

Give the woman a focus group card with her group number (1-4), the focus group location, phone number, and directions.

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