Survey screener - Family and Cultural Impact

“Family and Cultural Impact on STD and HIV Risk among Latino and African-American Youth”

Attachment 1b. Survey Screener

Form Approved

OMB No. 0920-0840

Expiration Date 01/31/2013

“Family and Cultural Impact on STD and HIV Risk among Latino and African-American Youth”

Survey Screener

Public reporting burden of this collection of information is estimated to average 7 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 NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0840)

PHONE SCRIPT for PROJECT FACTS

Research Staff: If receiving a call, read:

Hello, this is _________. How can I help you?

If caller is calling about FACTS, start reading at the asterisks**

John 8-28-08, Comment#14,

Research staff: If returning a call, read:

Hello, can I speak to [insert name of mom].

My name is _______ I received your message that you would like to be a part of the FACTS Project.

**Project FACTS is a Family Health research project at Cal State University Dominguez Hills. Is now a good time to ask you a few questions to see if you are eligible to participate in the study? It will only take about 5-10 minutes.

IF NO: Thank caller and ask for a good time to call back and obtain a call back number: (_____) _________________.

IF YES: Proceed with screening questions

What is your race/ethnic background? _________________________________

Are you a parent of a child or children between the ages of 12 to 15 years old that goes to Boys and Girls Club Activities?

IF NO: [Read] Thank you for your time. Unfortunately, you are not eligible to participate in the study. But we appreciate you taking the time to talk to us. Have a good day!

IF YES: [Read] What is/are the name/s of the child/ren between 12-15 years old? What is/are the gender/s and has she or he lived with you for half of the time in the past 2 years? [Write answers in box below]

Name of Child	___________	___________	___________	___________
Age of Child	______Years	______Years	______Years	______Years
Gender of Child	Male/Female	Male/Female	Male/Female	Male/Female
Has child lived with you half the time in the past 2 years?	Yes / No	Yes / No	Yes / No	Yes / No

Research Staff:

Proceed ONLY if the caller has lived with child/ren half the time in the past 2 years AND if there are spaces left for the child’s gender.

If caller is ELIGIBLE read at *! below.

If caller NOT ELIGLE read:

Thank you for your time. Unfortunately, you are not eligible to participate in the study. But we appreciate you taking the time to talk to us. Have a good day!

*!. You are eligible to take part in this study, let me tell you a little more about what we are doing. Project FACTS is a Family Health study at Cal State University, Dominguez Hills. In this project we are asking parents and their children to tell us about how they talk about sex. If you choose to take part in this study, you and your child will be asked to complete a survey on the computer that will take 60-90 minutes to do. We will ask questions about how family and culture affects the way you talk to your child/ren about sex. What you tell us in the survey will be kept secure by research staff. This study is completely voluntary and will either take place on the campus of California State University, Dominguez Hills or at your home. Each family will receive a token of appreciation of $50 in cash- $30 for the parents and $20 for the child.

Are you interested in participating?

IF NO: [Read] Thank you for your time. If you change your mind, please feel free to call us back anytime. Have a good day!

IF YES: [Read] Thank you! We have a few more questions to ask in order to place you in a focus group.

1. What's your name? ___________________________________________

2. Have you called the study before? Y N

3. How did you hear about our study?

_______________________________________________________

4. When are you and your child able to complete the surveys?

Research Staff:

Make sure that you tell the participants that the surveys must be done at the same time and emphasize that they will be completed in separate rooms.

Write answers below.

Date 1: Date 2: Date 3: Date 4:

Time 1: Time 2: Time 3: Time 4:

Research Staff:

Circle CSUDH if they prefer our campus or write down participant address if this is preference.

5. Where would you like to complete the surveys?

CSUDH

Address: ______________________________________________

(Street address) ______________________________________________

(City) (ZIP)

6. As soon as we assign a research assistant to conduct the surveys for you and your child we will call you to make sure that this date still works for you. Please give me a good number to reach you at. (_____)____________________.

7. Are there any questions you have for me?

IF NO: [Read] Thank you for agreeing to participate in this study. We will be calling you soon!

IF YES: [Answer questions]

[Read] Thank you for agreeing to participate in this study. We will be calling you soon!