Attachment F3: Eligibility Screening Interview
Form Approved
OMB #0920-XXXX
Exp. Date XX/XX/20XX
1. In order to determine if you are eligible to participate, I will ask you some questions about you, your job and work experience. May I go ahead?
YES 1 GO TO Q4a
NO 2
2. I can offer you a coupon worth $2 at this truck stop if you complete a quick, 2-minute interview. Would you be willing to do that?
YES 1 ADMINISTER NON-RESPONDENT
NO 2 INTERVIEW
INTERVIEWER NOTE:
IF Q3= 3, 4, 5, 6, 7 OR 91, USE STANDARD SURVEY TECHNIQUES FOR REFUSAL CONVERSION. ENCOURAGE PARTICIPATION IN FULL SURVEY, AND IF UNSUCCESSFUL ATTEMPT 2-MINUTE NON-RESPONDENT INTERVIEW.
3. Would you please let me know why you don’t wish to participate?
NOT A TRUCK DRIVER 1 NOT ELIGIBLE, TERMINATE
ALREADY PARTICIPATED…………………………... 2 NOT ELIGIBLE, TERMINATE
NOT AT THE TRUCK STOP LONG ENOUGH 3
TOO TIRED 4 IF CONVERSION
BUSY WITH SOMETHING ELSE 5 SUCCESSFUL, GO TO Q4a
PRIVACY CONCERNS 6 IF UNSUCCESSFUL
SURVEY TOPIC DOESN’T INTEREST ME 7 TERMINATE.
OTHER 91
(SPECIFY)
Public reporting burden of this collection of information is estimated to average 2 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 30329-4018; ATTN: PRA (0920-xxxx).
4a. We began collecting data at truck stops for this survey, the National Survey of Truck Driver Injury and Health on [DATE OF BEGINNING OF FIELD DATA COLLECTION]. Have you participated in this survey either at this location or at another truck stop?
YES 1 NOT ELIGIBLE, TERMINATE
NO 2
REFUSED -7
DON’T KNOW -8
4b. Is driving a truck your main occupation?
YES 1
NO 2
REFUSED -7 NOT ELIGIBLE, TERMINATE
DON’T KNOW -8
5. Do you drive a truck that has 3 or more axles? Your job would require you to have a Commercial Drivers License.
YES 1
NO 2
REFUSED -7 NOT ELIGIBLE, TERMINATE
DON’T KNOW -8
6. Have you driven such a vehicle for a total of 12 months or more?
YES 1
NO 2
REFUSED -7 NOT ELIGIBLE, TERMINATE
DON’T KNOW -8
7. Do you take at least one mandatory 10-hour rest period away from home during each delivery run?
YES 1
NO 2
REFUSED -7 NOT ELIGIBLE, TERMINATE
DON’T KNOW -8
8. Can you stay at this stop for at least 1 more hour?
YES 1
NO 2
REFUSED -7 NOT ELIGIBLE, GO TO Q11
DON’T KNOW -8
ACCEPTED INTO INTERVIEW.
Thank you for answering these questions. You are eligible to participate. The interview will last about 50 minutes and you will be given a $25 [gift card for this truck stop chain / OR cash card] at the end of the interview.
These discussions are anonymous. We will not ask for your name or any other identifiable information.
9. Would you like to participate?
YES 1 ADMINISTER CONSENT SCRIPT
NO 2 AND MAIN INTERVIEW
REFUSED -7
DON’T KNOW -8
INTERVIEWER NOTE:
AFTER ASKING Q10, USE STANDARD SURVEY TECHNIQUES FOR REFUSAL CONVERSION. ENCOURAGE PARTICIPATION IN THE FULL SURVEY. IF UNSUCCESSFUL, CONTINUE TO Q11.
10. May I ask why you don’t want to participate?
NOT AT THE TRUCK STOP LONG ENOUGH 1
TOO TIRED 2 IF CONVERSION
BUSY WITH SOMETHING ELSE 3 SUCCESSFUL, ADMINISTER
PRIVACY CONCERNS 4 CONSENT SCRIPT AND MAIN
SURVEY TOPIC DOESN’T INTEREST ME 5 INTERVIEW
OTHER 91
(SPECIFY)
11. I can offer you a coupon worth $2 at this truck stop if you complete a quick, 1-minute interview. Would you be willing to do that?
YES 1 GO TO Q12
NO 2 TERMINATE.
12. Do you consider yourself…
A company employee who does not lease, own,
or make payments on your truck? 1
An owner-operator who leases, owns or makes
payments on your truck and is leased to a
motor carrier? or 2
An owner-operator who leases, owns, or makes
payments on your truck and operates under
your own authority getting your own loads? 3
REFUSED -7
DON’T KNOW -8
13. Do you now smoke cigarettes every day, some days, or not at all?
EVERY DAY 1
SOME DAYS 2
NOT AT ALL 3
REFUSED -7
DON’T KNOW -8
14. ASK ONLY IF NECESSARY. OTHERWISE RECORD OBSERVATION.
Are you male or female?
MALE 1
FEMALE 2
REFUSED -7
DON’T KNOW -8
15. What year were you born?
1 9 |___|___| GO TO Q 16
REFUSED -7 GO TO Q 15a
DON’T KNOW -8 GO TO Q 15a
15a. Please tell me in which one of the following age categories you belong. Are you…
18 – 20, 1
21 – 30, 2
31 – 40, 3
41 – 50, 4
51 – 60, 5
61 – 70, or 6
71 or older? 7
REFUSED -7
DON’T KNOW -8
16. Please tell me your height and weight without shoes.
______ FEET ______ INCHES
REFUSED -7
DON’T KNOW -8
__________ POUNDS
REFUSED -7
DON’T KNOW -8
16a. Would you say your health in general is excellent, very good, good, fair, or poor?
excellent, ....................................................1
very good,....................................................2
good, ............................................................. 3
fair, or ............................................................ 4
poor............................................................... 5
REFUSED ..................................................... … .8
DON'T KNOW ............................................... .. .9
INTERVIEWER NOTE:
RECORD GENDER, APPROXIMATE AGE, HEIGHT, WEIGHT, AND CIGARETTE USE IF NONRESPONDENT DOES NOT ANSWER ANY OF Q 13-16.
Thank you for answering these questions. You are still eligible to participate in the full survey, if you wish. The interview will last about 50 minutes and you will be given a $25 [gift card for this truck stop chain / OR cash card]gift card for this truck stop at the end of the interview.
These discussions will be anonymous. We will not ask for your name or any other identifiable information.
17. Would you like to participate?
YES 1 ADMINISTER CONSENT SCRIPT
NO 2 AND MAIN INTERVIEW
REFUSED -7
DON’T KNOW -8
18. Would you please let me know why you don’t wish to participate in the full survey?
NOT AT THE TRUCK STOP LONG ENOUGH 1
TOO TIRED 2 IF CONVERSION
BUSY WITH SOMETHING ELSE 3 SUCCESSFUL, ADMINISTER
PRIVACY CONCERNS 4 CONSENT SCRIPT.
SURVEY TOPIC DOESN’T INTEREST ME 5 OTHERWISE TERMINATE.
OTHER 91
(SPECIFY)
| File Type | application/msword |
| File Title | Attachment F1: Screening Interview |
| Author | wks1 |
| Last Modified By | wks1 |
| File Modified | 2010-08-30 |
| File Created | 2010-08-30 |