Evaluation of health communication messages for
Infertility Prevention Campaign
0920-09XX
Attachment 3F
Online Screener & Survey: Female Adult & Minor (15-25 yr old)
Form approved
OMB no. 0920-XXXX
Expiration date xx/xx/20xx
Chlamydia Screening Online Materials
Online Screener & Survey: Female Adult & Minor
(15-25 yr old)
Public reporting burden of this collection of information is estimated to average 8 minutes per response, including the time for reviewing instructions and completing 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. 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 NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)
Recruit at least 100 girls ages 15–17 and 400 young women ages 18–25.
Invitation
Thank you for your interest in this survey. This study is for young women ages 15 through 25. It is being sponsored by the US Centers for Disease Control and Prevention (CDC). If you qualify for the survey and answer a few questions for us about a [web banner/web page/pop-up advertisement], you will receive [$2.00 to $5.00] toward your account. The questions will take up to 8 minutes of your time. The [web banner/web page/pop-up advertisement] is a public health message about avoiding complications from sexually transmitted diseases.
Your participation is entirely voluntary and there will be no physical risk to you. You do not have to answer questions that you don’t want to, and you may stop at any time.
Before taking the survey, you will need to answer a few questions to see if you qualify. If you qualify, you will be taken directly to the survey to answer questions about a poster. When you are finished the survey, you will be notified that [$2.00-$5.00] has been added to your account. If you do not qualify, you will find out right away, and you will not receive the incentive. Some of these questions may sound personal but this information will help make sure that a variety of people complete the survey. No one will see your responses, and you will not be asked to give your name. There is no way your answers can be connected back to you or your email address.
If you have questions about your rights as a research participant, you can call CDC directly at 1-800-584-8814. If you have specific questions or concerns about this research study, you can call Dr. Elyse Levine at (202) 884-8913. These contact numbers will be provided to you again at the end of the survey.
Click here if you are interested to see if you qualify for the reward.
The following questions will be answered by the participant through an online survey programmed to accept/terminate as indicated. The survey will end, at any point, if a participant does not qualify.
1. What is your age? _____ Record age
( ) Under 15 …………………………………………………………………..Terminate
( ) 15–17 Continue
( ) 18–25 Continue
( ) 26 or older Terminate
Recruit a mix between 15 and 25.
2. Have you participated in a market research study in the past 6 months, in which you were
paid to provide your opinions regarding a product, a service, or advertising on the topic of STDs or sexual/reproductive health?
( ) Yes Terminate
( ) No Continue
3. Have you ever, or do you currently work or volunteer in the field of sexual or reproductive
health?
( ) Yes Terminate
( ) No Continue
Do you feel comfortable responding to materials that require a 7th grade reading level?
( ) Yes Continue
( ) No Terminate
|
Yes |
No |
1. Have you ever had a pelvic exam or Pap test? |
|
|
2. Have you ever asked to be tested for a sexually transmitted disease (STD)? |
|
|
3. Have you ever had sexual intercourse? |
|
|
[Program will terminate only if “no” to all]
Are you Hispanic/Latina?
( ) Yes Continue
( ) No Continue
( ) Don’t Know Terminate
Program recruits according to sample needs.
Are you . . . ?
( ) African American/Black Continue
( ) Caucasian/White Continue
( ) Asian Terminate
( ) Native American Terminate
( ) Refused to answer Terminate
Program recruits according to sample needs.
Are you currently enrolled in high school, college, or trade school?
( ) Yes Continue
( ) No Continue
Program recruits a mix.
Do you currently live with your parents or guardians?
( ) Yes Continue
( ) No Continue
Program recruits a mix.
When was the last time you visited a doctor, nurse, or clinic?
( ) Within last six months Continue
( ) Within last year Continue
( ) Between one and two years ago Continue
( ) More than two years ago Continue
Program recruits a mix.
Invitation
Terrific! You qualify to participate and receive a gift certificate for [$2.00 to $5.00]. The purpose of this survey is to help CDC understand how to communicate with teens and young women about measures they can take now to protect their health and prevent infertility in the future. As was mentioned earlier, you will be shown a [web banner/web page/pop-up advertisement] and then asked for your honest feedback about it. This [web banner/web page/pop-up advertisement] is designed for women your age.
[Screen displays item with “continue” button] Please take a moment to look this over.
[Image will be included on all remaining survey pages]
Imagine this was a [item] on a web page somewhere—maybe on [insert name of popular social networking site], or on a television show website. How much does this [item] catch your attention? Please enter a number from 1-5 where the number 1 represents “not at all” and 5 represents “very much.”
[Screen shows “Not at all/Very much” scale]
1 2 3 4 5
How likely would you be to read this [item]? Please enter a number from 1-5 where the number 1 represents “not at all likely” and 5 represents “very likely.”
[Screen shows “Likelihood” scale]
1 2 3 4 5
How much of the [item] would you read?
[Screen shows the responses below]
( ) I would only read the headline
( ) I would only look at the image/s
( ) I would only read the headline and look at the image/s
( ) I would read the whole thing
( ) I wouldn’t read any of it
How easy is it to understand what the [item] is saying? Please enter a number from 1-5 where the number 1 represents “not at all easy” and 5 represents “very easy.”
[Screen shows “Not at all/Very easy” scale]
1 2 3 4 5
How much do you like the look of the [item]? Please enter a number from 1-5 where the number 1 represents “not at all” and 5 represents “very much.”
[Screen shows “Not at all/Very much” scale]
1 2 3 4 5
Would this [item] stand out on the type of web pages you typically use? Please enter a number from 1-5 where the number 1 represents “not at all” and 5 represents “very much.”
[Screen shows “Not at all/Very much” scale]
1 2 3 4 5
Do the people shown on the [item] seem like you, or people you know/would like to know? Please enter a number from 1-5 where the number 1 represents “not at all” and 5 represents “very much.”
[Screen shows “Not at all/Very much” scale]
1 2 3 4 5
How old does the person/people on the [item] look? Enter age or range ______________
How likely would you be to click on this [item] for more information? Please enter a number from 1-5 where the number 1 represents “not at all likely” and 5 represents “very likely.”
[Screen shows “Likelihood” scale]
1 2 3 4 5
(If a score of 3 or less is entered) Please indicate why you would not be likely to click on this web [item] (check all the reasons that apply).
( ) I don’t trust [item]
( ) I don’t have time
( ) It looks like a scam
( ) I never click on [item]
( ) There are too many other [item]
( ) The message is not compelling
( ) I don’t care about [the topic]
( ) [Item topic] is not relevant to me
After reading this [item], how likely are you to [take the action suggested in the item]? Please enter a number from 1-5 where the number 1 represents “not at all likely” and 5 represents “very likely.”
[Screen shows “Likelihood” scale]
1 2 3 4 5
(If a score of 3 or less is entered) Please indicate why you would not be likely to [take the action suggested in the item] (check all the reasons that apply).
( ) I don’t think it’s important
( ) I don’t have time
( ) I don’t have a way to pay for it
( ) I’m afraid [of/to INSERT action]
( ) I don’t have a health care provider
( ) I would be embarrassed
( ) I don’t trust [INSERT item]
( ) I don’t want anyone to suspect I’m [INSERT action]
( ) I wouldn’t know where to go [INSERT action]
( ) I don’t know how to [INSERT action]
( ) I don’t want my partner to find out
( ) I’m not at risk for STDs (if this response is selected, provide “because” options)
( ) Because I’m in a monogamous relationship
( ) Because I’m not currently sexually active
( ) Because I use protection
( ) Because I’m careful about my partners
( ) Other: ____________________
Is there anything you would change to make it more effective for young women your age? [Open ended answer]
Are there other products, besides [item] that would be more effective in getting your attention? [Open ended answer]
Thank you very much for your time. Your feedback has been really helpful. In order to receive your $5 gift certificate, please enter your e-mail address below. Your e-mail address will only be used to send your gift certificate; it will not be used for any other purpose, and it will not be linked to your answers. After you receive your gift certificate, you will receive no further e-mail from us.
If you have questions about this research, or if you think you have been harmed, you should talk to a parent, guardian, or doctor. You can also call CDC directly at 1-800-584-8814 with any questions about your rights as a participant. Leave a message with your name and phone number, and someone will call you back as soon as possible. If you have any other questions about the research, or if you think you have been harmed in any way by participating, please call Dr. Elyse Levine at (202) 884-8913.
Online
Survey Screener and Instrument
| File Type | application/msword |
| File Title | Infertility Prevention Campaign Formative Research Protocol Memorandum |
| Author | AED_USER |
| Last Modified By | vbs6 |
| File Modified | 2009-07-15 |
| File Created | 2009-06-15 |