Form 1 FLASHE Screener

Attachment 4F: Screener for FLASHE

OMB No.: 0925-0642

Expiration Date: 9/30/2014

Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285a). Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private under the Privacy Act. Names and other identifiers will not appear in any report of the study. Information provided will be combined for all study participants and reported as summaries. You are being contacted by telephone to complete this instrument so that we can identify potential sources of measurement or response error. The purpose of this instrument is to examine psychosocial, generational, and environmental correlates of cancer preventive behaviors.

Public reporting burden for 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0642). Do not return the completed form to this address.

INTRO

Screener for the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey

NAME____________________________ PHONE__________________________

RESPONDENT Number ____________________

Hello, my name is (NAME) and I’m calling from Westat, a research company in Rockville. May I speak with (NAME)?

(reintroduce yourself if needed)

Thank you for your interest in the Family Life, Activity, Sun, Health, and Eating (FLASHE) Survey. I would like to tell you a little bit about the study and then I’ll ask you a few questions to see if you are eligible to take part.

We’re looking for people to participate in a session that can last about an hour and a half. In that session you would meet with a Westat researcher who would ask you some questions from a survey that we’re developing about health, physical activity, and nutrition habits of parents or guardians and their teenage children. All the interviews are being conducted at Westat’s facilities in Rockville or Frederick, MD. Parents and guardians who participate will receive a cash gift of $75 in appreciation for their time, and their teenagers will receive $50.

If you are open to it, I would like to ask you a few questions to see if you and your teen are eligible to participate.

IF NEEDED: Westat, a research company in Rockville, Maryland is conducting survey research for the U.S. Department of Health and Human Services to test questions for an upcoming national survey – we’d like to get your opinion on whether the questions are easy to understand and answer.

Q1. As I said, these interviews will take place at Westat’s headquarters, located on Research Boulevard in Rockville, Maryland, or at a facility that Westat contracts with in Frederick, MD. Are you within driving or commuting distance to one of these locations?

PROVIDE MORE INFO ON LOCATIONS IF NEEDED

a. Yes, which one?

• Rockville

• Frederick

b. No – TERMINATE AND THANK (“Based on the study design, our interviews are going to be conducted at these locations, so it looks like we can’t include you at this time.”)

Q2. We are looking for pairs of one parent or guardian and one child between the ages of 11 and 18. Do you have at least one child in this age range?

• Yes

• No -- TERMINATE AND THANK (“Based on the study design, we need pairs of parents and children, so it looks like we can’t include you at this time.”)

Q3. What is your sex?

• Male

• Female

INTERVIEWER: RECRUIT A MIX OF MALES AND FEMALES.

Q4. Have you participated in a focus group or individual interview in the past three months?

• No

• Yes – COLLECT DEMOGRAPHIC INFORMATION, THANK, AND PLACE ON WAITING LIST (“For this study, we are looking for participants who have not taken part in a focus group or interview in the past three months, so it looks like we can’t include you at this time. If you would like, we can collect the rest of your information and place you on a waiting list.”)

Q5. Which of the following age categories are you in?

• 18 – 29

• 30 – 44

• 45 – 54

• 55 – 64

• 65 and older

INTERVIEWER: RECRUIT A MIX OF AGES, if possible.

Q6. Are you Hispanic, Latino/a or Spanish origin?

• Yes

• No

Q7. What is your race? MARK ALL THAT APPLY.

• White

• Black or African American

• Asian

• American Indian or Alaska Native

• Native Hawaiian or Other Pacific Islander

INTERVIEWER: RECRUIT SOME NON-WHITE RESPONDENTS.

Q8. What is the highest level of education you have completed?

• 11^th grade or less

• 12 years of school, no diploma

• GED or high school graduate (diploma)

• Some college or technical school

• College or technical school graduate

• Post-graduate

INTERVIEWER: TRY TO RECRUIT A MIX OF RESPONDENTS FROM EACH EDUCATION GROUP.

Q9. What is the age and sex of the child that you would also like to participate?

• Male age ______

• Female age ______

INTERVIEWER: RECRUIT A MIX OF CHILD AGES AND GENDERS.

Q10. Is this child:

• Hispanic, Latino/a or Spanish Origin

• Not Hispanic, Latino/a or Spanish Origin

Q11. What is this child’s race? MARK ALL THAT APPLY.

• White

• Black or African American

• Asian

• American Indian or Alaska Native

• Native Hawaiian or Other Pacific Islander

INTERVIEWER: RECRUIT SOME NON-WHITE RESPONDENTS.

Closing #1

You and your child are eligible to help with this research project. Just to give you a little more information, we’ll be asking people about their lifestyle behaviors, such as exercise habits and diet. Please note, we will not share your personal information with anyone not involved in this study. Are you interested in participating?

YES — Thank you so much for your willingness to help us. If you are selected as a participant you will receive $75 cash upon completion of the interview, and your child will receive $50 as a thank you for participating. If you are chosen as a participant, I will call you back within two business days to set up a time for you to meet with someone from the study team.

NO — Thank you for taking the time to talk with me today and have a great (day/evening).

Closing #2

Thank you for answering those questions. We will contact you within the next week to indicate if you are eligible to help with this research project.

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