OMB# 0584-0523
Expiration Date: 12/31/2012
Public reporting burden for this collection of information is estimated to average 10 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: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0523*). Do not return the completed form to this address.
Appendix A
Screening Questionnaire for Consumer Focus Groups
Interviewer: _______________
Date: _______________
Letter sent: _______________
Reconfirmation Call: _______________
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Group I ______
Group II ______
Group III ______
Group IV ______
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Hello, I’m __________ with __________________, an independent consumer research firm. We are not selling or promoting any product or service. We are conducting a research study on behalf of the United States Department of Agriculture, Center for Nutrition Policy and Promotion regarding food choices and nutrition and would like to include your views. My questions will only take a couple of minutes.
1. First, do you, or does any member of your household or immediate family, work for or is retired from:
A market research company _____
A direct mail company or direct marketing company _____
An advertising agency or public relations firm _____
[IF YES TO ANY >> TERMINATE]
2. Please tell me your occupation and the name of the company or organization you work for (if retired get former occupation and company worked for).
____________________________________________________________
____________________________________________________________
[TERMINATE IF DIETITIAN, NUTRITIONIST, NURSE, PHYSICIAN OR PHYSICIAN’S ASSISTANT, OR IF THEY WORK FOR USDA OR HHS]
3. Are you the parent or guardian of a child [or children] between the ages of 5 and 12, who lives in your household?
Yes _____
TERMINATE >> No _____
4. Have you ever had bariatric surgery? Bariatric surgery is weight loss surgery.
TERMINATE >> Yes _____
5. In a typical month, how frequently do you shop at a grocery store, food store or supermarket for your household?
4 or more times _____
2 or 3 times _____
TERMINATE >> Fewer than 2 times _____
6. What is your height? _____________
What is your weight? _____________
[CALCULATE BMI USING ONLINE CALCULATOR]
TERMINATE >> BMI less than 19 _____
BMI 19-24 _____
BMI 25-35 _____
TERMINATE>> BMI greater than 35 _____
7. Do you have a medical condition that requires a special diet or restricted diet?
Yes _____
ACCEPT [BUT NO MORE THAN 3 PER GROUP]: High cholesterol/high lipid levels (also called: Hypercholesterolemia, Hyperlipidemia, Dyslipidemia), hypertension/high blood pressure, pregnancy, gout, chronic constipation, heartburn/GERD, migraines, menopause, osteoporosis, food allergy
TERMINATE: all other medical conditions mentioned
8. Which of the following categories best describes your total annual household income?
TERMINATE >> Under $15,000 _____
$15,000 - $34,999 _____
$35,000 - $54,999 _____
$55,000 - $74,999 _____
$75,000 - $100,000 _____
TERMINATE >> Over $100,000 _____
9. How often does your family eat DINNER together in a typical week? |
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Every day 5 pts |
5-6 times/week 4 pts |
3-4 times/week 3 pts |
1-2 times/week 2 pts |
Less than once/week 1 pt |
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10. How often does your family prepare DINNER at home in a typical week, as opposed to having “take-out,” a frozen dinner or dinner in a restaurant? |
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Every day 5 pts |
5-6 times/week 4 pts |
3-4 times/week 3 pts |
1-2 times/week 2 pts |
Less than once/week 1 pt |
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11. How many servings of vegetables, on average, does your family have for DINNER each night? |
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2 or more servings per night 5 pts |
1 serving per night 3 pts |
Less than 1 serving per night 1 pt |
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12. How would you rate the overall healthfulness of your family’s eating habits? |
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Excellent 5 pts |
Very Good 4 pts |
Good 3 pts |
Fair 2 pts |
Poor 1 pt |
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Calculate total points for questions 7-10, and assign to group based on number of points:
4-12 points = Group A [RECRUIT 2 “A” GROUPS PER LOCATION]
13-20 points = Group B [RECRUIT 2 “B” GROUPS PER LOCATION]
12. Please tell me your age. [GET EXACT AGE AND CATEGORIZE BELOW]
[GOOD MIX OF AGES, WITH THE UNDERSTANDING THAT THE EXTREMES AT EITHER END ARE UNLIKELY, GIVEN THESE ARE PARENTS/GUARDIANS OF CHILDREN 5-12]
18-22_____
23-34 _____
35-44 _____
45-54 _____
55-64 _____
65 or older _____
13. What is your current marital status? Are you ….. ? [
Married or living with a partner_____
Single _____
Divorced _____
Widowed _____
15. What is the highest level of education you have completed? [GOOD MIX]
Less than high school graduate _____
High school graduate _____
Some college _____
Post graduate studies or degree _____
16. So that we can be sure that all backgrounds are represented in our study, please tell me your ethnic or race background. Are you … ?
[RECRUIT 2-3 MINORITIES PER GROUP]
Ethnicity
Hispanic or Latino_____
Not Hispanic or Latino_____
Race
American-Indian or Alaska Native _____
Asian _____
Black or African American _____
Native Hawaiian-Indian or Other Pacific Islander _____
White _____
Other _____
17. [Record gender] [TRY FOR MIX, WILL LIKELY BE FEMALE DOMINANT]
Male _____
18. Have you ever attended a focus group discussion or individual interview? By that we mean an informal, round-table discussion, conducted by a professional moderator in which you were asked your opinions regarding a product, a service, or advertising?
MAX. ½ GROUP >> ASK A-C >> Yes _____
INVITE TO GROUP >> No _____
How many of these groups have you attended?
______________________________ [MAX. 3 EVER]
What was/were the topics discussed?
______________________________ [IF NUTRITION, TERMINATE]
How long ago was the last one of these groups you attended?
______________________________ [MUST BE AT LEAST 6 MONTHS AGO]
[INVITE TO GROUP]
Thank you for answering all of my questions. As I mentioned earlier, we are conducting a research study regarding food choices and nutrition and would like to hear your views. To hear them first-hand, we are conducting an informal, round-table discussion to be held on [DATE] at [TIME]. The discussion will last about 2 hours and will be both fun and informative. No one will attempt to sell you anything and no one will call on you as a result of your participation. As a token of our appreciation for your help in our research effort, you will receive a [$75- $100] cash honorarium at the time of the session. This is an important research effort and we hope that you will be part of it. We can only invite about a dozen people to take part. Can we schedule your attendance?
[If yes, read ….. ]
If you need glasses for reading or for watching TV, please be sure to bring them with you to the group.
ID Number _________________________________________________
NAME: _________________________________________________
ADDRESS: _________________________________________________
CITY: _________________________________________________
ZIP CODE: _________________________________________________
PHONE: (DAY) _____________________________________
(EVE) _____________________________________
(CELL _____________________________________
(EMAIL) _____________________________________
Interviewer: ____________________
Supervisor Confirm: ____________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | dbailey |
| File Modified | 0000-00-00 |
| File Created | 2021-02-03 |