Form Attachment 3: Fema Attachment 3: Fema Attachment 3: Female Screener

ATTACHMENT 3

Female Parent Recruit/Screener

OMB No. 0930-0196

Expiration Date: 09/30/2013

Public Burden Statement: 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. The OMB control number for this project is 0930-0196. Public reporting burden for this collection of information is estimated to average 10 minutes per respondent per year, as no time is necessary for reviewing instructions, searching existing data sources, gathering and maintaining data, nor completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 8-1099, Rockville, Maryland, 20857.

SAMSHA Underage Drinking Prevention

National Media Campaign

FEMALE PARENT Recruit/Screener

Sample Selection

• Participants should be recruited for 1 of 5 focus groups.

• A total of 12 participants should be recruited for each group. Only 8 participants will be required for each group.

• The objective is to obtain female parents of children ages 9 to 15.

• Participants should be recruited from a cross section of race/ethnicity, socioeconomic status, and rural/urban/suburban groups.

• Only one participant per household.

INTRODUCTION

Hello, my name is ____________ and I am calling from Gallup. We are interested in talking to groups of parents to understand their thoughts about issues relating to their children.

The purpose of these groups is to gather insights to help the U.S. Government develop an underage drinking prevention education program for parents. This is a unique opportunity to make a valuable contribution to your community and the Nation.

The discussion groups will be held at a professional focus group facility in your community. We are offering a $50 gift card as a way to say thank you for participating in the discussion.

INTERVIEWER

1. May I ask you a few questions to see if you qualify for our focus groups?

01 YES (Continue)

02 NO (Thank and terminate)

2. Gender:

1. Female (Continue)

2. Male (Switch to Male Recruit Screener)

3. Are you the mother or primary caregiver of a child between the age of 9 and 15?

1. YES, mother (Continue)

2. YES, primary caregiver (if selected, ask, what is your relation to the

child_____________________)

03 NO (Thank and terminate)

4. Have you ever attended a focus group discussion?

01 Yes—go to item 4b below

02 No—Continue to #5

4b. How many group discussions have you attended in the past 12 months?

RECORD #_______________

IF MORE THAN 3, THANK AND TERMINATE

5. Have you recently participated in a Gallup focus group on underage drinking?

01 Yes—THANK AND TERMINATE

02 No—Continue

6. On a scale of 1 to 6, where “1” is “Very Uncomfortable” and “6” is “Very Comfortable,” how comfortable do you feel expressing your opinion in a group with 8 or 9 other people?

VERY UNCOMFORTABLE VERY COMFORTABLE

1 2 3 4 5 6

MUST ANSWER 4, 5, OR 6

7. Are you of Hispanic or Latino ethnicity?

1. Yes

2. No

8. What is your race? (Mark all that apply)

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or Other Pacific Islander

5. White

9. We are looking for a specialized group of parents with children of a certain age.

Do you have a child living in your household that’s between the ages of_______?

GROUPS 6 & 8

1. 9-12 (RECRUIT FOR 1 GROUP IN CLEVELAND AND 1 GROUP IN RALEIGH)

01 YES (Continue)

02 NO

GROUPS 7, 9, & 10

2. 13-15 (RECRUIT FOR 1 GROUP IN NEW YORK CITY, 1 GROUP IN OMAHA, AND 1 GROUP IN LOS ANGELES)

1. YES (Continue)

2. NO

RECRUITER NOTE: If NO to ALL questions 8a-8b, THANK AND TERMINATE

Recruiter Grid:

	Central Region (Cleveland)	Northeast Region (New York City)	Southeast Region (Raleigh)	Southwest Region (Omaha)	Western Region (Los Angeles)
Mothers
9-12	Group 6		Group 8
13-15		Group 7		Group 9	Group 10

CLOSE

Our group will be held on DATE at TIME at LOCATION. Will you be able to participate?

DATE TIME LOCATION

IF GROUP 6 participant READ: TBD TBD TBD

IF GROUP 7 participant READ: TBD TBD TBD

IF GROUP 8 participant READ: TBD TBD TBD

IF GROUP 9 participant READ: TBD TBD TBD

IF GROUP 10 participant READ: TBD TBD TBD

If YES to participating, READ and collect the following information:

Thanks for agreeing to participate. I just have a few additional questions.

10. What is a telephone number where we can reach you to remind you of the date and time of the group session?

Telephone #: ___________________________

10. Do you have e-mail address we can also use to contact you? If YES, record address below.

E-MAIL: _______________________________________________

DEMOGRAPHICS

D1. Age (RECRUIT A MIX):

1. Below 40

2. 40-55

3. 55-65

4. 65+

D2. Would you say you live in a/an __________community? (RECRUIT A MIX)

1. Urban

2. Suburban

3. Rural

D3. Annual household income? (RECRUIT A MIX)

01 Less than $25,000

02 $25,000 to $34,999

03 $35,000 to $49,999

04 $50,000 to $74,999

05 $75,000 to $99,999

06 $100,000 to $149,999

07 $150,000 or more

Final Notes and Incentive Information

• Participants must show up at the facility at least 15 minutes prior to the start of the group.

• Participants will receive a $50 gift card. If they arrive after the group has begun they will not receive a gift card.