Attachment 8: Screening Script for the Observational Feeding Study
NCI Feeding Study Telephone Participation Screener/Confirmation Script
DRAFT
ID: | | | |
OMB #: 0925-xxxx
Expiry Date: xx/xx/20xx
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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx). Do not return the completed form to this address. |
INTRODUCTION: Hello, may I speak with [RESPONDENT NAME]?
[IF NOT AVAILABLE, ASK]: When would be a good time to reach [RESPONDENT]? RECORD BEST DAY AND TIME ON CALL RECORD.
IF SOMEONE OTHER THAN RESPONDENT ASKS REASON FOR CALL:
My name is [INTERVIEWER NAME]. I'm calling from Westat, a research firm located in Rockville, Maryland.
IF RESPONDENT IS AVAILABLE:
Hello, my name is [INTERVIEWER NAME]. I'm calling from Westat, a research firm located in Rockville, Maryland. I am calling to ask you to take part in a study to help us learn about how people think about food. The study will only take about 3 hours of your time over a two day period. If you choose to participate, we will ask you to come to our research facility in Rockville, Maryland to eat breakfast, lunch, and dinner on one day. Each meal will take approximately 45 minutes. The next day, we will ask you to attend a 45 minute visit to the same research facility to answer questions about your diet and health. You will receive $120 for your time. It is very important that you attend both days of the study. Being part of this study does not involve any risk to your health. .
This research is authorized by the Public Health Service Act, and of course, your participation is entirely voluntary. Be assured there will be no consequences if you decide not to participate, either to the study as a whole or to any particular questions. Also, all of your answers will be kept confidential, and the results of the study will be reported only as grouped data with no individual data reported.
AGREE I would like to ask if you would like to participate in this project.
a. YES 01
b. NO 02 [THANK AND END]
DOB I’d like to confirm the year were you born? [READ FROM CALL RECORD] 19_________
IF born after 1989 thank and end.
ATTEND In order to participate, you will need to come to our research facility on two consecutive days. Are you able to come to Westat, located in Rockville, for breakfast, lunch, and dinner on one day, and then return the very next day for an interview session?
a. YES 01
b. NO 02 [THANK AND END]
INTERNET Do you have access to high-speed internet at your house?
a. YES 01
b. NO 02 [THANK AND END]
ENGWELL With regard to the English language, how well do you…?
a. understand it when it is spoken to you?
1. Some but not too well 01
2. Well 02
3. Very well 03
IF RESPONDENT HAS TROUBLE WITH THIS QUESTION: We are interested in your own opinion of how well you understand English when it is spoken to you. Would you say you
a. understand spoken English?
1. Some but not too well 01
2. Well 02
3. Very well 03
b. how well do you speak English?
1. Some but not too well 01
2. Well 02
3. Very well 03
c. how well do you read English?
1. Some but not too well 01
2. Well 02
3. Very well 03
[IF ANY ANSWER TO ENGWELL=01, THANK AND END]
GENDER If not obvious, ask: For the record, are you male or female?
a. Male 01
b. Female 02
ASK NEXT, PREGNANT QUESTION TO FEMALES ONLY:
PREGNANT Are you currently pregnant?
a. YES 01 [THANK AND END]
b. NO 02
DPREF Do you have dietary preferences that cause you to be unable to eat the majority of foods offered to you?
a. YES 01 [THANK AND END]
b. NO 02
ALLERGY Are you allergic to any foods?
a. YES 01 [THANK AND END]
b. NO 02
WTLOSS Are you currently trying to lose weight by dieting, taking medication, or using a liquid diet?
a. YES 01 [THANK AND END]
b. NO 02
SURGERY Have you had any type of bariatric surgery for weight loss, such as gastric staples, or bands?
a. YES 01 [THANK AND END]
b. NO 02
NUTREDUC Have you had any formal training or education in the field of nutrition, such as an associate, bachelor, or graduate-level degree in dietetics, nutrition, food science, or home economics?
a. YES…………………………….….. 01 [THANK AND END]
b. NO 02
PHONENUM For this study, it is very important that we are able to reach you. What is the best phone number at which to reach you in the…
Daytime? _____________________________________
Evening? _____________________________________
ADDRESS I would also like to confirm your mailing address so that we can mail project related materials. [READ FROM CALL RECORD]
Record Address: _____________________________________________________
___________________________________________________________________
RACEETH1 Do you consider yourself to be …
Hispanic or Latino 01
Not Hispanic or Latino 02
RACEETH2 For this next question, you may choose as many answers as apply. Do you consider yourself to be …
American Indian or Alaska Native Yes No
Asian Yes No
Black or African-American Yes No
Native Hawaiian or Other Pacific Islander Yes No
White Yes No
Prefer not to answer Yes
QUESTION Do you have any questions about what you’ll be doing in the study?
(Use FAQs to respond to questions).
END Thank you for taking the time to talk with me today. We will be contacting you soon to schedule your visits to our research facility.
| File Type | application/msword |
| File Title | ASA24 Comparison Study Telephone Participation Screener/Confirmation Script |
| Author | dixit-joshi_s |
| Last Modified By | Vivian Horovitch-Kelley |
| File Modified | 2009-08-03 |
| File Created | 2009-07-30 |