Expiration Date: 9-30-13
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 3 minutes per respondent per year, including time for responding to questions, reviewing message concepts provided, and sharing reactions and ideas within the group. 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 2-1057, Rockville, Maryland, 20857.
Gender: (CODE DO NOT ASK)
Female ______ (RECRUIT ALL FEMALE GROUP 1, 4, 6, and 8)
Male ______ (MIXED GROUPS MALE/FEMALE 2, 3, 5, and 7)
Assigned group ______________
Sample Selection
Participants should be recruited for 1 of 8 telephone focus groups.
A total of 14 participants should be recruited for each group. Only 8 participants will be required for each group.
The objective is to obtain as many participants as possible who:
Are parents or caretakers of family members (children, older, disabled).
Have experienced a major natural or made-made disaster within the last 10 years.
Experienced distress related to that disaster.
Participants will be from disaster-prone zip codes in four areas (Gulf coast, California and the Pacific Northwest, the Mid-West, and the East Coast). You will be working from a list of possible participants from either rural or a non-rural locations within one of these areas.
Only one participant per household is eligible for the focus groups.
Introduction
Hello, my name is ____________ and I am calling from the Gallup Organization. We are interested in talking to people who have been through a disaster.
We are pulling together groups of people to talk about the kind of help people who have been through a disaster might need. This is a unique opportunity to make a valuable contribution to your community and the Nation.
The groups will be conducted over the telephone so you don’t have to go anywhere. We are also offering a $50 gift card as a way to say thank you for participating in the discussion.
Interviewer
First, I have a question to see if qualify for a group.
Have you experienced a major man-made or natural disaster in the last 10 years? (Note: examples of disasters include: hurricane, flood, fire covering a large territory, tornado, earthquake, major air disaster, oil spill, terrorist bombing, etc. Disasters affecting only individual families do not qualify.)
1. YES (Continue to 1a&b below)
NO (Thank and terminate)
RECORD RESPONSES
1a. What type of disaster was it? ________________
1b. When did it occur? ________________________
Disaster’s sometimes affect people’s emotions, like feeling stressed or sad. On a scale of 1-10, how much did the disaster affect your emotions, either at the time or later? “1” is if the disaster did not affect your emotions at all and “10” is if the disaster greatly affected your emotions.
DID NOT AFFECT GREATLY AFFECTED
1 2 3 4 5 6 7 8 9 10
MUST ANSWER 6 OR ABOVE
3. Are you the parent of a child (up to age 18), or a caregiver for an older (over age 65) or disabled relative?
YES (Continue)
NO (Thank and terminate)
4. Have you ever attended a group discussion for market research purposes?
Yes ( ) go to item (b) below
No ( ) go to (Continue)
4b.How many group discussions have you attended in the past 12 months?
RECORD #_______________
IF MORE THAN 3, TERMINATE
5. 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 eight or nine other people?
VERY UNCOMFORTABLE VERY COMFORTABLE
1 2 3 4 5 6
MUST ANSWER 4, 5, OR 6
6. Thank you, you are eligible to participate and now I’d like to try to find a time when you will be able to join a group.
ASSIGN PARTICIPANT TO ONE OF THESE GROUPS:
Disaster- Prone Areas Within… |
Caretaker Women |
Caretaker Mixed |
Gulf Coast |
||
Rural
|
Group #1 |
|
Non-rural
|
|
Group #2 |
California and Pacific Northwest
|
||
Rural
|
|
Group #3 |
Non-rural
|
Group #4 |
|
Mid-West |
||
Rural
|
Group #5 |
|
Non-rural
|
|
Group #6 |
East Coast |
||
Rural
|
|
Group # 7 |
Non-rural |
Group #8 |
|
Our group will be held on DATE at TIME. Will you be able to participate?
DATE TIME
Gulf Coast
Rural (women only) XX XX
Non-rural (mixed) XX XX
California/Pacific N.W.
Rural (mixed) XX XX
Non-rural (women only) XX XX
Mid-West
Rural (women only) XX XX
Non-rural (mixed ) XX XX
East Coast
Rural (mixed) XX XX
Non-rural (women only) XX XX
If YES to participating READ and collect the following information
READ: As part of the requirement for the group, we will be mailing you a packet with materials you will need to participate as well as your $50 gift card.
7. Can I verify the spelling of your name?
NAME: ____________________________
8. What is your mailing address?
ADRRESS LINE 1:_______________________________________
ADDRESS LINE 2:_______________________________________
CITY, STATE, ZIP: _______________________________________
9. What is your telephone number so we can reach you to verify that you received the packet?
Telephone #: ___________________________
10. Do you have email address we can also use to contact you? If YES, record address below.
EMAIL:_______________________________________________
READ: We are almost done, I just need to collect some additional information about you:
D1. Age: (RECRUIT A MIX)
Below 40
40-55
55-65
65+
D2. Would you say you live in a/an __________community? (RECRUIT A MIX)
Urban
Suburban
Rural
D3a. Are you of Hispanic or Latino origin or descent?
Yes( )
No ( )
D3b. Would you say your race is? (Tell me all that apply.) (RECRUIT A MIX)
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian or Other Pacific Islander
White
D4. What is your annual household income?
01 Under $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 and over
Final Notes and Incentive Information
Participants must join the focus group from a quiet room with a telephone.
Participants will receive a $50 gift card.
CLOSE AND THANK PARTICIPANT
Gender: (CODE DO NOT ASK)
Female ______ (RECRUIT A MIX)
Male ______ (RECRUIT A MIX)
Sample Selection
Participants should be recruited for 1 of 2 telephone focus groups.
A total of 14 participants should be recruited for each group. Only 8 participants will be required for each group.
Participants should have called the Disaster Distress Helpline at some point.
Only one participant per household is eligible for the focus groups.
Introduction
Hello, my name is ____________ and I am calling from the Gallup Organization. You recently gave your permission for us to contact you to ask you about your experience calling the Disaster Distress Helpline.
We are pulling together groups of people to talk about the kind of help people who have been through a disaster might need. This is a unique opportunity to make a valuable contribution to your community and the Nation.
The groups will be conducted over the telephone so you don’t have to go anywhere. We are also offering a $50 gift card as a way to say thank you for participating in the discussion.
Interviewer
First, I have a question to see if qualify for a group.
1. Are you the parent of a child (up to age 18), or a caregiver for an older (over age 65) or disabled relative?
YES
NO
2. Have you ever attended a group discussion for market research purposes?
Yes ( ) go to item (b) below
No ( ) go to (Continue)
2b.How many group discussions have you attended in the past 12 months?
RECORD #_______________
IF MORE THAN 3, TERMINATE
3. 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
4. Thank you, you are eligible to participate and now I’d like to try to find a time when you will be able to join a group.
5. Are you 18 years of age or older?
1. Yes
2. No [TERMINATE]
ASSIGN PARTICIPANT TO ONE OF THESE GROUPS:
Our group will be held on DATE at TIME. Will you be able to participate?
DATE TIME
Callers Group 1 XX XX
Callers Group 2 XX XX
If YES to participating READ and collect the following information
READ: As part of the requirement for the group, we will be mailing you a packet with materials you will need to participate as well as your $50 gift card.
6. Can I verify the spelling of your name?
NAME: ____________________________
7. What is your mailing address?
ADRRESS LINE 1:_______________________________________
ADDRESS LINE 2:_______________________________________
CITY, STATE, ZIP: _______________________________________
8. What is your telephone number so we can reach you to verify that you received the packet?
Telephone #: ___________________________
9. Do you have email address we can also use to contact you? If YES, record address below.
EMAIL:_______________________________________________
READ: We are almost done, I just need to collect some additional information about you:
D1. Age: (RECRUIT A MIX)
Below 40
40-55
55-65
65+
D2. Would you say you live in a/an __________community? (RECRUIT A MIX)
Urban
Suburban
Rural
D3a. Are you of Hispanic or Latino origin or descent?
Yes( )
No ( )
D3b. Would you say your race is? (Tell me all that apply.) (RECRUIT A MIX)
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian or Other Pacific Islander
White
D4. What is your annual household income?
01 Under $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 and over
Final Notes and Incentive Information
Participants must join the focus group from a quiet room with a telephone.
Participants will receive a $50 gift card.
CLOSE AND THANK PARTICIPANT
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Hello, my name is ____________ and I am calling from the Gallup Organization |
| Author | Alison Simon |
| File Modified | 0000-00-00 |
| File Created | 2021-02-02 |