Form 3 Testing of Sexual Violence Definitions and Recommended D

APPENDIX 9: PHASE 2 SCREENING SCRIPT

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Public reporting burden of this collection of information is estimated to average 5 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 Rd NE, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-XXXX).

___________

Final Outcome Code

NOTE TO REVIEWERS: DIFFERENT VERSIONS OF THIS INSTRUMENT WILL BE PREPARED FOR EACH OF THE THREE COMMUNITIES. THEY ARE COMBINED INTO ONE DOCUMENT FOR PURPOSES OF REVIEW ONLY.

Screener Form (SF)

A Study of Women’s Well Being

Conducted by

For

The Centers For Disease Control and Prevention

FI NAME:

FI ID #:

Case Information

Community: HOUSTON/ATLANTA/SEATTLE

Case ID: FI ID:

Address: Apt:

City: State: Zip:

Screener Form (SF)

1. IS THERE A HOUSING UNIT (HU) AT THE ADDRESS SHOWN ON THE ASSIGNMENT LABEL?

YES 1 → GO TO Q.2

NO 2

1A. CIRCLE THE NUMBER BELOW WHICH BEST DESCRIBES WHY THERE IS NO HU AT THIS ADDRESS

(CIRCLE ONE ONLY):

CONDEMNED 1

DEMOLISHED 2

PLACE OF BUSINESS WITHOUT RESIDENCE 3

NO SUCH ADDRESS, NO SUCH HU 4

GROUP QUARTERS 5

VACATION CABIN 6

NOT USABLE AS A PERMANENT RESIDENCE 7

TRANSIENT USE (LESS THAN ONE MONTH) 8

NOT AN HU FOR OTHER REASON (SPECIFY BELOW) 9

UNDER CONSTRUCTION 10

1B. DESCRIBE HOW YOU DETERMINED THE ADDRESS WAS NOT AN HU:

1C. DISPOSITION THIS CASE AS “20 – NOT AN HU.” DISCUSS WITH YOUR FIELD MANAGER. IF SHE APPROVES, WRITE “80” AS FINAL OUTCOME CODE ON COVER.

COMPLETE THE NON-INTERVIEW QUEX.

FINALIZE CASE AS “80” 80

2. WAS ANYONE LIVING AT THIS HU WHEN YOU MADE YOUR FIRST VISIT THERE?

YES 1→ GO TO Q.3

NO 2

2A. HOW MANY VISITS WERE MADE TO THE HU?

#OF VISITS:

2B. WHO CONFIRMED THAT THE HU WAS VACANT? CIRCLE ALL THAT APPLY.

NEIGHBOR 1

NON-RESIDENT WHO WAS AT THE HU 2

MAIL CARRIER 3

JANITOR OR SUPER 4

DOORMAN OR DOOR WOMAN 5

OTHER (SPECIFY) 6

2C. DESCRIBE HOW YOU DETERMINED THE HU WAS VACANT.

2D. DISPOSITION THIS CASE AS “21 – VACANT HU.” DISCUSS WITH YOUR FIELD MANAGER. IF S/HE APPROVES, WRITE “81” AS FINAL OUTCOME CODE ON COVER.

COMPLETE THE NON-INTERVIEW QUEX

FINALIZE CASE AS “81” 81

3. IS ANYONE LIVING AT THIS HU ABLE TO SPEAK ENGLISH OR SPANISH?

YES 1→ GO TO SF INTRO

NO 2

3A. WHAT LANGUAGE DO THEY SPEAK?

3B. DESCRIBE HOW YOU DETERMINED THAT NO ONE SPEAKS ENGLISH OR SPANISH.

______________________________________________________________________________________

3C. DISPOSITION THIS CASE AS “23 – NO SELECTED LANGUAGE SPOKEN IN HU.” DISCUSS WITH YOUR FIELD MANAGER. IF SHE APPROVES, WRITE “83” AS FINAL OUTCOME CODE ON COVER.

FINALIZE CASE AS “83” 83

SF – Introduction to Household

READ: Hello, I’m [NAME] from NORC, A National Organization for Research at the University of Chicago.

FI INFO: SHOW ID BADGE.

READ: The Centers for Disease Control and Prevention recently sent a letter to this address. The letter explained that this house had been selected to take part in A Study of Women’s Well Being. As part of this study, we will ask women questions about sexual violence. We want to learn more about how often sexual violence happens, when and where it happens, and how it happens. The study will take place in Houston, Texas; Atlanta, Georgia; and Seattle, Washington. The National Opinion Research Center is conducting the study.

4. First, I’d like to make sure I am at the correct address. Is this (READ ADDRESS FROM ASSIGNMENT LABEL ON COVER)?

YES, CORRECT ADDRESS 1→ GO TO Q.5A

NO, ADDRESS IS NOT CORRECT 2→ GO TO Q.4A

4A. IF DIFFERENT IN ANY WAY, REVIEW THE FACESHEET AND RECONCILE.

IF DIFFERENCE CAN’T BE RESOLVED, CALL YOUR FIELD MANAGER BEFORE CONTINUING. EXPLAIN THE DIFFERENCE HERE:

______________________________________________________________________________________

______________________________________________________________________________________

NOW GO TO Q.5A

5A. Only one woman in your household may be eligible for this survey. In order to scientifically select that person, first I need to list the names of the women who usually live here. Please tell me the names or initials of each woman age 18 and above who usually lives in this household. Let’s begin with the eldest woman living in your household and list the women who are 18 years or older. (I don’t need her full name; initials or a nickname is fine.)

FI INFO: LIST ON ROWS A – H BELOW.

5B. Are there any other women age 18 and above who live here?

FI INFO: LIST ADDITIONAL PERSONS ON ROWS B – H BELOW.

5C. Have we forgotten any women, such as: tenants; people who usually live here, but are away temporarily – on business trips, at school, temporarily in a hospital, and so on?

YES 1 → LIST ADDITIONAL PERSONS ON ROWS B – H

NO 2 → GO TO Q. 5D

5D. HOW MANY WOMEN ARE NOW LISTED ON THE ROSTER?

ONE OR MORE 1 → ASK Q.6

NONE 2 → SKIP TO Q. 13

6. Are there any women currently staying here – visitors, including friends, or relatives – who do not usually live here?

FI INFO: “VISITORS” ARE PEOPLE WHO HAVE STAYED 4 OR MORE OF THE PREVIOUS 7 NIGHTS.

YES 1 → LIST VISITORS ON ROWS I – K BELOW, THEN ASK Q.7

NO 2 → ASK Q.7

FI INFO: AFTER Qs. 5 – 6, ASK Qs. 7 A, B, OR C (BASED ON LOCALITY) FOR EACH WOMAN.			11. 7A. IN HOUSTON AREA ASK: Does (NAME)/ Do you consider herself/yourself to be Hispanic or Latina ? Yes…………………..CIRCLE 1 No………………….. CIRCLE 2 DK/REFUSED………CIRCLE 2 7B. IN ATLANTA AREA ASK: Does (NAME)/ Do you consider her self /yourself to be: White ……….CIRCLE 2 Black or African American ……….CIRCLE 1 American Indian or Alaska Native ……….CIRCLE 2 DK/REFUSED…CIRCLE 2 7B. IN SEATTLE AREA ASK: Does (NAME)/Do you consider her self /yourself to be: White ……….CIRCLE 2 Black or African American ……….CIRCLE 2 American Indian or Alaska Native ……….CIRCLE 1 DK/REFUSED…CIRCLE 2
ROW	WOMEN AGE 18 AND ABOVE : NAME , INITALS, OR NICKNAME	1		2
A		1		2
B		1		2
C		1		2
D		1		2
E		1		2
F		1		2
G		1		2
H		1		2
I		1		2
J		1		2
K		1		2

8. Are any of the women we have listed staying somewhere else right now?

YES 1 → ASK Q.9

NO 2 → GO TO Q.11

FI INFO: “STAYING SOMEWHERE ELSE” MEANS BEING AWAY 4 OR MORE OF THE PREVIOUS 7 NIGHTS.

9. Who is staying somewhere else right now? CHECK (√) ROW OF EACH PERSON WHO IS AWAY.	10. ASK FOR EACH PERSON CHECKED IN Q.9: Where is (NAME) staying right now: Is (NAME) staying at another household; is (s/he) traveling; is (s/he) in some institution or dormitory – like at college, or in a hospital or something; or what? CIRCLE APPROPRIATE INSTRUCTIONS BELOW AND CROSS THAT ROW OUT OR LEAVE IT IN AS INSTRUCTED.
IF AWAY	IN OTHER HU	TRAVELING	INSTITUTION	OTHER/DK
	X OUT	LEAVE IN	X OUT	CALL FM
	X OUT	LEAVE IN	X OUT	CALL FM
	X OUT	LEAVE IN	X OUT	CALL FM
	X OUT	LEAVE IN	X OUT	CALL FM
	X OUT	LEAVE IN	X OUT	CALL FM
	X OUT	LEAVE IN	X OUT	CALL FM
	X OUT	LEAVE IN	X OUT	CALL FM
	X OUT	LEAVE IN	X OUT	CALL FM
	X OUT	LEAVE IN	X OUT	CALL FM
	X OUT	LEAVE IN	X OUT	CALL FM
	X OUT	LEAVE IN	X OUT	CALL FM
	X OUT	LEAVE IN	X OUT	CALL FM
	X OUT	LEAVE IN	X OUT	CALL FM
	X OUT	LEAVE IN	X OUT	CALL FM

11. ARE ANY WOMEN CODED ‘2” AT Q.7?

YES 1 → X OUT

NO 2 → GO TO Q.12

12. HOW MANY WOMEN AGED 18 OR OLDER ARE NOW ON THE ROSTER?

NONE (GO TO Q. 13) 1

ONE (GO TO Q.15; THAT PERSON IS THE RESPONDENT) 2

TWO OR MORE (GO TO Q.14, SELECT THE RESPONDENT) 3

13. This study concerns issues affecting (Hispanic/African American/Native American) women in this community. There are no eligible respondents living in this household. On behalf of the Centers for Disease Control and Prevention, thank you for your time and assistance.

RECORD DISPOSITION ON COVER AND CONTACT INFORMATION ON ROC

14. In order to select a respondent to take part in this study, could you tell me, of (READ NAMES LEFT ON ROSTER), who has had the most recent birthday? IF RESPONDENT ASKS "WHY?" SAY:] Our research experts specify this method to randomly select the woman in your household I should speak to, so that all types of eligible women are represented in this study.

FI INFO: CIRCLE NAME OF SELECTED RESPONDENT ABOVE; THEN ASK Q.15

15. ([SELECTED NAME] has / You have) been selected. If I have to talk with ([SELECTED NAME / you), what phone number should I use? WRITE NAME AND PHONE NUMBER HERE AND RECORD ON ROC.

SELECTED R NAME: PHONE NUMBER: ( )

16. Where is this phone?

In this household 1

In home of neighbor 2

Cell phone 3

Other (SPECIFY) 4

IF NO NUMBER GIVEN:

NO PHONE 5

REFUSED PHONE NUMBER 6

17. If I have to mail a note to ([SELECTED NAME] / you), what would be the best mailing address to use?

FI INFO: WRITE HERE AND RECORD ON ROC.

P.O. BOX OR APT NO.
NO. AND STREET / RFD NO.
CITY OR POST OFFICE, STATE, ZIP

18. IS RESPONDENT AVAILABLE FOR INTERVIEWING RIGHT NOW?

YES 1 → BEGIN

NO 2 → 1. THANK INFORMANT;

→ 2. TRY TO MAKE APPT WITH SELECTED R,

→ 3. FINISH Qs. 19 - 21

19. RECORD DATE SF ADMINISTERED: MONTH DAY

20. RACE OF HOUSEHOLD BY OBSERVATION:

WHITE 1

BLACK/AFRICAN AMERICAN 2

AMERICAN INDIAN 3

ASIATIC, ORIENTAL 4

OTHER, MIXED, UNABLE TO OBSERVE 5

21. CIRCLE ROW LETTER OF SELECTED RESPONDENT FROM ROSTER:

A B C D E F G H I J

A9-2