Form no number no number Eligibility Script

Randomized Controlled Trial for Routine Screening for Intimate Partner Violence

ATTACHMENT I - Eligibility script

Eligibility Script for Pretest

OMB: 0920-0761

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Attachment I. Eligibility script


Hi, I’m _________________. I work for the Research Collaborative Unit at Stroger Hospital. We’re doing a study on women’s health.


Do you have access to a phone where we can call you to ask you some questions?

(If no) That’s o.k. Thank you. STOP

(If yes) Good. Thank you.


Research Assistant will determine, by observation, if patient is ineligible because of visual, hearing, or mental impairment; or accompanied by a child over age three with no other adult supervision or a companion who refuses to separate from her.


(If not eligible) Patient will be thanked.

(If eligible) We’d like to invite you to participate in our study (Continue with consent form).


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File Created2021-02-02

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