Field Test Survey Instrument (Web and Telephone)

ATTACHMENT 3B

WEB FIELD TEST SURVEY INSTRUMENT

Form Approved

OMB No. 0920-XXXX

Exp. Date __xx/xx/20xx________

Public reporting burden of this collection of information is estimated to average 18 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: PRA (0920-0762)

Introduction, Consent

[INTRO:] The U.S. Department of Health and Human Services is interested in learning about all the ways people get information about health. This voluntary interview takes about 18 minutes. You don’t have to answer any question you don’t want to, and you can stop at any time. Your opinions will help improve health communication and all the information you give will be confidential.

Module A. Core communication

A1. I-info seek

First, I’d like to ask a general question. Some people get information about health or a medical topic only from a doctor and some people have lots of ways. If you wanted information about how to stay healthy, about a sickness, or about some medical topic, what are all the ways you would try to get that information? [DO NOT READ CATEGORIES. CODE ALL THAT APPLY.] PROBE TWICE: Any other sources for health information? PROBE ONE MORE TIME: Any others?

	FAMILY/FRIENDS/CO-WORKERS/NEIGHBORS	1
	DOCTORS, NURSES, OR OTHER HEALTH PROFESSIONALS	2
	HOSPITAL/CLINIC	3
	COMMUNITY/SENIOR CENTER/SCHOOL	4
	RELIGIOUS ORGANIZATION/LEADERS	5
	TV/RADIO	6
	GOVERNMENT HEALTH AGENCIES (E.G.,CDC, NIH; LOCAL PUBLIC HEALTH AGENCIES) GOVERNMENT WEB SITES (E.G., CDC.GOV) OR TELEPHONE NUMBERS (E.G., 1-800-4-CANCER, 1-800-CDC-INFO)	7
	NON-GOVERNEMENT ORGANIZATIONS (E.G., RED CROSS)	8
	NON-GOVERNMENT WEB SITES (E.G., WEBMD.COM, REDCROSS.ORG., GOOGLE) OR TELEPHONE NUMBERS (E.G., 1-800-REDCROSS)	9
	BROCHURES/PAMPHLETS/POSTERS	10
	NEWSPAPERS/MAGAZINES	11
	BOOKS/ LIBRARY	12
	DO NOT TRY TO GET HEALTH INFORMATION	13
	OTHER (SPECIFY)_______________________	91
	REFUSED	-7
	DON’T KNOW	-8
A2. A-info seek	Do you have access to the internet from a home computer?

YES	1	[GO TO NEXT Q
NO	2	[GO TO CELL PHONE Q
REFUSED	-7	[GO TO
DON'T KNOW	-8	[GO TO

A3. A-info seek

At home, do you use a dial-up connection through a standard telephone line or do you have a high-speed internet connection such as a cable or DSL line?

DIAL UP CONNECTION	1
HIGH SPEED	2
REFUSED	-7
DON’T KNOW	-8

A4. A-info seek

Some people get emails with information that they are interested in. What type of emails about health and safety, if any, would you be willing to receive from government health agencies? Would you say…[CODE ALL THAT APPLY.]

General health and safety information and tips	1
Vital, emergency-related information only, or	2
None at all	3
DON’T HAVE EMAIL	4
REFUSED	-7
DON'T KNOW	-8

A5. Do you have a cell phone?

YES	1	[GO TO A6]
NO	2	[GO TO A8]
REFUSED	-7	[GO TO A8]
DON'T KNOW	-8	[GO TO A8]

A6. A-info seek

Can you send and receive text messages on your cell phone?

YES	1	[GO TO A7]
NO	2	[GO TO A8]
NO CELL PHONE/ DON’T TEXT MESSAGE	3	[GO TO A8]
REFUSED	-7	[GO TO A8]
DON'T KNOW	-8	[GO TO A8]

A7. A-info seek

What type of text messages, if any, would you be willing to receive from government health agencies? How about…[CODE ALL THAT APPLY.]

General health and safety information and tips	1
Vital, emergency-related information only, or	2
None at all	3
NO CELL PHONE/ DON’T TEXT MESSAGE	4
REFUSED	-7
DON'T KNOW	-8

A8.	Next, I’d like your opinion on information about health. Please tell me whether you strongly agree, agree, disagree, or strongly disagree with the following statements. [ROTATE START.]

	[REPEAT RESPONSE CATEGORIES IF NECESSARY.]	Strongly agree	Agree	Disagree	Strongly disagree	refused	don’t know
a. I-attitudes, culture/vals	It’s important to have information about how to prevent future health problems.	1	2	3	4	-7	-8
b. SN-info seek	People often ask me about health or medical topics.	1	2	3	4	-7	-8
c. I, SS, CMM-attitudes	It’s hard to find health information that I can trust.	1	2	3	4	-7	-8
d. SN-social norms	When it comes to health, I generally do what my family and friends expect of me.	1	2	3	4	-7	-8
e. I, SS, CMM-knowledge, self-eff	If a new disease started, I wouldn’t not know where to get good information.	1	2	3	4	-7	-8
f. SN- soc cap	Besides my family, there are people who live near me whom I can rely on in case I need a ride to visit my health care provider.	1	2	3	4	-7	-8
g. I-affect	I sometimes feel overwhelmed by the amount of health information that is available.	1	2	3	4	-7	-8
h. I-knowledge	I pay attention to health news stories on the TV or radio.	1	2	3	4	-7	-8
i. I-self-eff	I can get all the information I need to take good care of my health.	1	2	3	4	-7	-8
j. SS.CMM-attitudes	Part of the government’s job is to provide the public with health information.	1	2	3	4	-7	-8

Module B. Seasonal Influenza

B1. I-knowledge

Now I’d like to ask you about a specific health topic, seasonal flu. Every year some types of flu go around. How much have you heard about seasonal flu? Would you say you’ve heard…

A lot of information,	1
Some,	2
A little, or	3
Nothing at all about seasonal flu?	4
REF	-7
DK	-8

B2. I-perceived suscept

Do you think you will get the seasonal flu this year? Would you say it’s…

Very likely,	1
Somewhat likely,	2
Not too likely, or	3
Not at all likely?	4
REF	-7
DK	-8

B3. I-perceived sever

If you got the seasonal flu how much harm would it cause you? Would you say…

A lot of harm,	1
Some harm,	2
A little harm, or	3
No harm?	4
REF	-7
DK	-8

B4. I-exper

Have you ever been sick with the seasonal flu?

YES	1
NO	2
REFUSED	-7
DON'T KNOW	-8

B5. I-knowledge, attitude, cult/vals

How important is it for people to protect themselves and prevent the spread of the seasonal flu? Would you say…

Very important,	1
Somewhat important,	2
Not too important, or	3
Not at all important?	4
REF	-7
DK	-8

B6. I-info seek

If you wanted to get information on how to protect yourself and prevent the spread of the seasonal flu, what are all the ways you would try to get that information? [DO NOT READ CATEGORIES. CODE ALL THAT APPLY.] PROBE ONCE: Any other sources? PROBE ONE MORE TIME: Any others?

FAMILY/FRIENDS/CO-WORKERS/NEIGHBORS	1
DOCTORS, NURSES, OR OTHER HEALTH PROFESSIONALS	2
HOSPITAL/CLINIC	3
COMMUNITY/SENIOR CENTER/SCHOOL	4
RELIGIOUS ORGANIZATION/LEADERS	5
TV/RADIO	6
GOVERNMENT HEALTH AGENCIES (E.G.,CDC, NIH; LOCAL PUBLIC HEALTH AGENCIES) GOVERNMENT WEB SITES (E.G., CDC.GOV) OR TELEPHONE NUMBERS (E.G., 1-800-4-CANCER, 1-800-CDC-INFO)	7
NON-GOVERNEMENT ORGANIZATIONS (E.G., RED CROSS)	8
NON-GOVERNMENT WEB SITES (E.G., WEBMD.COM, REDCROSS.ORG., GOOGLE) OR TELEPHONE NUMBERS (E.G., 1-800-REDCROSS)	9
BROCHURES/PAMPHLETS/POSTERS	10
NEWSPAPERS/MAGAZINES	11
BOOKS/ LIBRARY	12
DO NOT TRY TO GET HEALTH INFORMATION	13
OTHER (SPECIFY)__________________	91
REFUSED	-7
DON’T KNOW	-8

B7. I-knowledge

What are the important things to do, to protect yourself and prevent the spread of the seasonal flu? [DO NOT READ CATEGORIES. CODE ALL THT APPLY. PROBE: Anything else?]

GET A FLU SHOT	1
WASH HANDS OFTEN/KEEP HANDS CLEAN	2
PRACTICE PROPER SNEEZING/COUGHING	3
HAVE MEDICAL SUPPLIES ON HAND	4
HAVE EXTRA FOOD, WATER,AND MEDICINE ON HAND	5
HAVE A PLAN TO CARE FOR SICK FAMILY MEMBERS	6
DRESS WARMLY	7
GET EXTRA REST/SLEEP	8
TAKE VITAMINS	9
STAY HOME FROM WORK/SCHOOL/CHURCH IF SICK	10
OTHER (SPECIFY)______________	91
REFUSED	-7
DON’T KNOW	-8

B8. I-know, past behave, skill	Did you get a seasonal flu shot in the past 12 months?
	YES	1
	NO	2
	REFUSED	-7
	DON'T KNOW	-8

PROGRAMMER NOTE:

IF = 1, GO TO B9.

IF = 2, GO TO B10.

IF = -7 OR -8, GO TO B11.

B9. I, SN, A, PS- benefits

Please tell me the reasons you got a seasonal flu shot in the past 12 months. [DO NOT READ CATEGORIES. CODE ALL THAT APPLY. PROBE TWICE: Any other reason?]

I-knowledge, resp effic	DIDN’T WANT TO GET THE FLU/ IT WILL KEEP ME FROM GETTING THE FLU	1
I-past behave, self effic	ALWAYS GET ONE	2
A-benefits	IT DOESN’T COST MUCH/ INSURANCE PAYS	3
A- benefits	DOCTOR RECOMMENDED IT	4
SN- social norms	FAMILY/FRIENDS ALL GOT ONE	5
A, PS- attitudes	CONVENIENT TO GET/CAN GET IT AT WORK/COMMUNITY CENTER/CHURCH/DRUGSTORE	6
	OTHER (SPECIFY)______________	91
	REFUSED	-7
	DON’T KNOW	-8

PROGRAMMER NOTE: GO TO B11.

B10. I- barriers

Please tell me the reasons why you didn’t get a seasonal flu shot in the past 12 months. [DO NOT READ CATEGORIES. CODE ALL THAT APPLY. PROBE TWICE: Any other reason?]

I-suscep	NEVER GET THE FLU	1
I-sever	FLU ISN’T SERIOUS ENOUGH FOR A SHOT	2
A-barriers	CAN’T AFFORD/NO INSURANCE	3
A, PS- know	DIDN’T KNOW WHERE TO GET ONE	4
I, A, PS- barriers	NO PLACE TO GET ONE	5
I,CMM-know	NEVER HEARD OF FLU SHOTS	6
I-know	DIDN’T NEED ONE/NEVER GET ONE	7
I-resp effic, exper	GIVES YOU THE FLU/DOESN’T WORK	8
I, A, PS- affect	AFRAID OF NEEDLES/DOCTORS/CLINICS	9
I, A, PS- barriers	NO ONE TO TAKE ME TO GET ONE	10
SN- barriers	FRIENDS/FAMILY DON’T WANT ME TO GET ONE	11
SN- culture/values	FRIENDS/FAMILY SAY/HEARD IT DOESN’T WORK	12
SN- social norms	NO ONE I KNOW GETS ONE	13
I- skills	FORGOT	14
	OTHER (SPECIFY)______________	91
	REFUSED	-7
	DON'T KNOW	-8

B11. I-intention	Do you plan to get a seasonal flu shot in the next 12 months?
	YES	1
	NO	2
	REFUSED	-7
	DON'T KNOW	-8

Module C. Pandemic Influenza

C1. I-knowledge

Now, I’d like to ask you some questions about pandemic flu. How much have you heard about pandemic flu, for example, swine flu, also called H1N1, or bird flu? Would you say you’ve heard…

A lot of information,	1
Some,	2
A little, or	3
Nothing at all about pandemic flu?	4
REFUSED	-7
DON'T KNOW	-8

C2. I-perceived susceptibility/attitude

As you may know, a pandemic flu has the possibility to spread rapidly and kill hundreds of thousands of people. How likely is it that the area where you live would be affected by a flu pandemic? Would you say…

Very likely,	1
Somewhat likely,	2
Not too likely,	3
Not at all likely?	4
REFUSED	-7
DON'T KNOW	-8

C3. I-perceived sever

If a flu pandemic started spreading, how much harm do you think it could cause in your area? Would you say…

A lot of harm,	1
Some harm,	2
A little harm, or	3
No harm?	4
REF	-7
DK	-8

C4. I-perceived sever

If it started spreading in your area, how much harm do you think a flu pandemic could cause you?

A lot of harm,	1
Some harm,	2
A little harm, or	3
No harm?	4
REFUSED	-7
DON’T KNOW	-8

C5. I-perceived susceptibility/attitude

How likely do you think it is that you would be affected by a flu pandemic? Would you say it’s…

Very likely,	1
Somewhat likely,	2
Not too likely, or	3
Not at all likely?	4
REFUSED	-7
DON'T KNOW	-8

C6. I-info seeking, attitudes

People can get information from different sources. Please tell me how much you would trust information about how to prepare for a flu pandemic from each of the following sources. How about [READ ITEM]? Would you say you trust information about how to prepare for a flu pandemic from [READ ITEM] a lot, somewhat, a little, or not at all? [ROTATE START]

		a lot	somewhat	a little	not at all	ref	dk
a.	Government health agencies [IF NECESSARY: For example, CDC, NIH, or your local public health department.]	1	2	3	4	-7	-8
b.	TV or radio	1	2	3	4	-7	-8
c.	The internet	1	2	3	4	-7	-8
d.	Doctors or other health professionals	1	2	3	4	-7	-8
e.	Newspapers, magazines or books	1	2	3	4	-7	-8
f.	Community organizations, like senior centers or schools	1	2	3	4	-7	-8
g.	Religious organizations or leaders	1	2	3	4	-7	-8
h.	Family and friends	1	2	3	4	-7	-8

C7. SN- social norms, culture/vals; P- collect effic, soc cap	Do you think that most people will follow the recommendations of government health agencies to prepare for a flu pandemic?
	YES	1
	NO	2
	REFUSED	-7
	DON'T KNOW	-8

Module D. Climate Change Module

D_INTRO We’ve talked about some diseases people can catch. Now I’d like to ask you about a different topic, global warming, which is also called climate change.

D1. I-knowledge

How much have you heard about the risks to health because of global warming? Would you say you have heard…

A lot of information,	1
Some,	2
A little, or	3
Nothing at all about the health risks of global warming	4
REF	-7
DK	-8

D2. I-knowledge; attitudes

How likely is it that global warming will increase health risks for people in the U.S.? Would you say…

Very likely,	1
Somewhat likely,	2
Not too likely,	3
Not at all likely?	4
REFUSED	-7
DON'T KNOW	-8

D3. I-perceived susceptibility, attitude	Scientists have concluded that global warming will cause extreme weather, like more severe heat waves, severe hurricanes, dangerous flooding, and serious droughts. How likely is it that the area where you live will experience an extreme weather event like that in the next 12 months? Would you say… [DO NOT PROBE DON’T KNOW.]
	Very likely,	1
	Somewhat likely,	2
	Not too likely, or	3
	Not at all likely?	4
	REFUSED	-7
	DON'T KNOW	-8

D4. I-perceived susceptibility, attitude	Extreme weather events can affect health. For example, heat waves can cause breathing problems and hurricanes can cause injuries. How likely is that your health will be affected because of extreme weather events? Would you say it’s… [DO NOT PROBE DON’T KNOW.]
	Very likely,	1
	Somewhat likely,	2
	Not too likely,	3
	Not at all likely?	4
	REFUSED	-7
	DON'T KNOW	-8

D5. I-exper	Have you ever personally experienced any of the following events…
			yes	no	refused	don’t know
		A severe heat wave	1	2	-7	-8
		A severe hurricane	1	2	-7	-8
		A dangerous flood	1	2	-7	-8
		A serious drought	1	2	-7	-8

D6. I-perceived susceptibility, attitude	Some scientists also believe that global warming will lead to an increase in the US in the diseases mosquitoes carry, for example, West Nile virus or dengue [DEN-GAY] fever. How likely is it that people in the area where you live will be exposed to this kind of health risk in the near future? Would you say it’s… [DO NOT PROBE DON’T KNOW.]
	Very likely,	1
	Somewhat likely,	2
	Not too likely, or	3
	Not at all likely?	4
	REFUSED	-7
	DON'T KNOW	-8

D7. I-perceived susceptibility, attitude

How likely is that you will be exposed to diseases like West Nile virus or dengue [DEN-GAY] fever that are carried by mosquitoes? Would you say it’s… [DO NOT PROBE DON’T KNOW.]

Very likely,	1
Somewhat likely,	2
Not too likely, or	3
Not at all likely?	4
REFUSED	-7
DON'T KNOW	-8

D8. I-Skills; Information seeking	Have you ever tried to find information on the possible risks to your health caused by global warming?
	YES	1
	NO	2
	REF	-7
	DK	-8

D9. I-Skills; Information seeking

Will you try to find information about the health risks caused by global warming in the next 12 months?

YES	1
NO	2
REF	-7
DK	-8

D10. I-info seek

If you wanted to get information on how to protect your health from risks caused by global warming, what are all the ways you would try to get that information? [DO NOT READ CATEGORIES. CODE ALL THAT APPLY.] PROBE ONCE: Any other sources? PROBE ONE MORE TIME: Any others?

FAMILY/FRIENDS/CO-WORKERS/NEIGHBORS	1
DOCTORS, NURSES, OR OTHER HEALTH PROFESSIONALS	2
HOSPITAL/CLINIC	3
COMMUNITY/SENIOR CENTER/SCHOOL	4
RELIGIOUS ORGANIZATION/LEADERS	5
TV/RADIO	6
GOVERNMENT HEALTH AGENCIES (E.G.,CDC, NIH; LOCAL PUBLIC HEALTH AGENCIES) GOVERNMENT WEB SITES (E.G., CDC.GOV) OR TELEPHONE NUMBERS (E.G., 1-800-4-CANCER, 1-800-CDC-INFO)	7
NON-GOVERNEMENT ORGANIZATIONS (E.G., RED CROSS)	8
NON-GOVERNMENT WEB SITES (E.G., WEBMD.COM, REDCROSS.ORG., GOOGLE) OR TELEPHONE NUMBERS (E.G., 1-800-REDCROSS)	9
BROCHURES/PAMPHLETS/POSTERS	10
NEWSPAPERS/MAGAZINES	11
BOOKS/ LIBRARY	12
DO NOT TRY TO GET HEALTH INFORMATION	13
OTHER (SPECIFY)____________________	91
REFUSED	-7
DON’T KNOW	-8

D11. I-information seeking, attitudes; P-soc capital

Would you say you would trust information about the health risks of global warming from [FIRST ITEM] a lot, somewhat, a little, or not at all? [NEXT ITEMS, AS NECESSARY: How about from…] [ROTATE START. DO NOT PROBE DON’T KNOW.]

	[REPEAT RESPONSE CATEGORIES IF NECESSARY.]		a lot	some-what		a little		not at all		ref		dk
a.	Government health agencies [IF NECESSARY: For example, CDC, NIH, or your local public health department.]	1			2		3		4		-7		-8
b.	TV or radio	1			2		3		4		-7		-8
c.	The internet	1			2		3		4		-7		-8
d.	Doctors or other health professionals	1			2		3		4		-7		-8
e.	Newspapers, magazines or books	1			2		3		4		-7		-8
f.	Community organizations, like senior centers or schools	1			2		3		4		-7		-8
g.	Religious organizations or leaders	1			2		3		4		-7		-8
h.	Family and friends	1			2		3		4		-7		-8

Audiences for Climate Change

D12. Assuming global warming is happening, do you think it is …

Caused mostly by human activities or	1
Caused mostly by natural changes in the environment?	2
OTHER (specify)________________	91
GLOBAL WARMING ISN’T HAPPENING	4
REFUSED	-7
DON'T KNOW	-8

D13. How worried are you about global warming?

Very worried,	1
Somewhat worried,	2
Not too worried,	3
Not at all worried?	4
REFUSED	-7
DON'T KNOW	-8

D14. How much do you think global warming will harm you personally?

A great deal,	1
A moderate amount,	2
Only a little, or	3
Not at all?	4
REFUSED	-7
DON'T KNOW	-8

D15. When do you think global warming will start to harm people in the United States? Would you say…

They are being harmed now,	1
In 10 years,	2
In 25 years,	3
In 50 years,	3
In 100 years, or	3
Never?	4
REFUSED	-7
DON'T KNOW	-8

D16. How much do you think global warming will harm future generations of people?

A great deal,	1
A moderate amount,	2
Only a little, or	3
Not at all?	4
REFUSED	-7
DON'T KNOW	-8

D17. How important is the issue of global warming to you personally?

Extremely important,	1
Very important,	2
Somewhat important	3
Not too important, or	4
Not at all important?	5
REFUSED	-7
DON'T KNOW	-8

D18. Do you agree or disagree with the following statement: “I could easily change my mind about global warming.” Would you say you…

Strongly agree,	1
Somewhat agree,	2
Somewhat disagree, or	3
Strongly disagree?	4
REFUSED	-7
DON'T KNOW	-8

D19. How many of your friends share your views on global warming? Would you say…

None,	1
A few,	2
Some,	3
Most, or	4
All?	5
REFUSED	-7
DON'T KNOW	-8

D20. Which of the following statement comes closest to your views? [CODE ONE.]

Global warming isn’t happening,	1
Humans can’t reduce global warming, even if it is happening	2
Humans could reduce global warming, but people aren’t willing to change their behavior, so we’re not going to	3
Humans could reduce global warming, but it’s unclear at this point whether we will do what’s needed	4
Humans can reduce global warming, and we’re going to do it successfully	5
OTHER (specify)________________	91
GLOBAL WARMING ISN’T HAPPENING	4
REFUSED	-7
DON'T KNOW	-8

D21. Do you think citizens themselves should be doing more or less to address global warming? Would you say they should do…

Much more,	1
More,	2
They’re currently doing the right amount,	3
They should do less, or	4
Much less?	5
REFUSED	-7
DON'T KNOW	-8

Module E. Demographics

E INTRO. Finally, I’d like to ask you some questions for statistical purposes.

E1. [RECORD SEX; CONFIRM IF NECESSARY.]

MALE	1
FEMALE	2
REFUSED	-7
DON'T KNOW	-8

E2.	Are there any children age 17 or younger living in your household?

YES	1	[GO TO E3]
NO	2	[GO TO E4]
REFUSED	-7	[GO TO E4]
DON’T KNOW	-8	[GO TO E4]

E3.	Are any of these children age 6 or younger?

YES	1
NO	2
REFUSED	-7
DON’T KNOW	-8

E4. P-social capital

How long have you lived in the neighborhood where you live now?

LESS THAN I YEAR	1
1 TO 2 YEARS	2
MORE THAN 2 YEARS BUT LESS THAN 5 YEARS	3
5 YEARS OR MORE	4
REFUSED	-7
DON'T KNOW	-8

E5A.	What was the total income of all persons in your household over the past year, including salaries or other earnings, interest, retirement, and so on for all household members? Was it...

$25,000 or less, or	1	[GO TO CLOSE]
More than $25,000?	2	[GO TO E5B]
REFUSED	-7	[GO TO CLOSE]
DON’T KNOW	-8	[GO TO CLOSE]

E5B.

Was it...

$50,000 or less, or	1	[GO TO CLOSE]
More than $50,000?	2	[GO TO E5C]
REFUSED	-7	[GO TO CLOSE]
DON’T KNOW	-8	[GO TO CLOSE]

E5C.

Was it...

$75,000 or less, or	1
More than $75,000?	2
REFUSED	-7
DON’T KNOW	-8

THANK. I really appreciate your answering these questions. Thank you so much for your time.

18