Form #1 Form #1 Screening Questionnaire

A

Form Approved
OMB No. 0935-0179
Exp. Date 07/31/2014

ttachment A

Patient-Centered Outcomes Research Awareness Campaign

Focus Groups Screening Instrument

DRAFT 9.23.11

Call

Introduction

Hello, my name is _______________ and I’m from (name of company). I am calling on behalf of RTI International, a non-profit research organization, and the Agency for Healthcare Research and Quality (AHRQ). AHRQ is a federal agency under the US Department of Health and Human Services.

I am not selling any product. I am calling to invite people in (Chicago/Memphis) to join in focus group discussions as part of a research study to get opinions on some advertisements that are in development.

If you are eligible and choose to participate in the focus group, you will receive $75 as a token of our appreciation for taking time to participate in this important study and for any direct costs you may incur as a result of your participation.

To see if you are eligible for this study, we need to ask you some questions about you and your health. It is your choice to answer these questions. Your answers will be kept private to the extent permitted by law. You can refuse to answer a question or stop at any time.

If you are not eligible and/or choose not to be part of the study, all responses you give me today will be destroyed and you will not be contacted again.

Are you interested in possibly participating in this focus group study?

Yes..................1 Continue

No....................2 End

My questions will only take a few minutes. May I ask you the questions now?

Yes..................1 Continue

No....................2 End

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0179) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Segment	Chicago Groups	Memphis Groups
Caregivers	1	1
Engaged patients – Active info seekers	2	1
Engaged patients – Passive info seekers	2	1

1. Has a physician told you that you currently have one or more of the following?

Cancer?...................................................	1
Asthma?...............................................	2
Epilepsy?..............................................	3
Sickle Cell Disease?………………………….	4
High blood pressure?	5	For one or more, continue (as patient/caregiver) as needed to fill
Type 2 diabetes?	6
High cholesterol?	7
Heart disease?	8
None of the above	9	[CONTINUE TO #3]

2. What, if any, medications has your doctor prescribed to treat your [QUESTION 1 condition]?

If a medication is mentioned	1	Continue to #4
Otherwise…………………………….	2	[THANK & END]

3. Are you a primary caregiver or parent of someone with one or more of the following?

Cancer?...................................................	1
Asthma?...............................................	2
Epilepsy?..............................................	3
Sickle Cell Disease?………………………….	4	CONTINUE (as caregiver)
High blood pressure?	5
Type 2 diabetes?	6
High cholesterol?	7
Heart disease?	8
None of the above	9	[THANK & END]

4. In the past 12 months, how many times have you been to see your primary healthcare provider [for patients]/ the primary healthcare provider of the person you care for [for caregivers] because you/they had a health concern or question?

0-2	1	[THANK & END]
3 or more …………………………….	2	Continue
Don’t know …………………………….	3	[THANK & END]

5. Please think back to a health-related question or concern you [for patients]/ the person you care for [for caregivers] had in the past 6 months. When you/they had this question or concern, did you do any of the following? [Note: if participant has #1 PLUS any other of numbers 2-6, they will qualify as an ACTIVE INFO SEEKER. If participant only chooses #1, they will qualify as a PASSIVE INFO SEEKER]

[READ LIST]

Talked to my healthcare provider provieerprovider...................................................	1	Continue
Looked online for information int...............................................	2	Continue: ACTIVE INFO SEEKER
Talked to friends	3	Continue: ACTIVE INFO SEEKER
Talked to family	4	Continue: ACTIVE INFO SEEKER
Looked for information on tv/in books	5	Continue: ACTIVE INFO SEEKER
Other _________________ None of the above	6	Continue: ACTIVE INFO SEEKER

None of the above None of the above

9

[THANK & END]

6. What is your gender?

Female	1	Achieve a roughly ½ and ½ mix.
Male	2

7. Do you or does anyone else in your immediate family or household work… [READ LIST.]

In marketing research?	1	[THANK & END]
For a pharmaceutical or medical device company?	2
In public health or healthcare?	3
None	4	Continue

8. How old are you?

Record age: ________

[Achieve mix of roughly half above and half below 40]

9. Are you Hispanic or Latino/Latina?

Yes………………………………………………………	1
No	2

10. What is your race? Please select one or more. [READ LIST IF NECESSARY]

American Indian or Alaska Native……	1	[recruit mix]
Asian………………………………….	2
Native Hawaiian or Other Pacific Islander	3
Black or African American……………………………….	4
White……………………………………..	5

11. What is your current relationship status? Are you…?

Single	1
Married ……………………………	2
In a relationship …………………….	3
Divorced or Widowed	4
Married	5
Refused	6

12. What is your yearly individual income? [READ LIST IF NECESSARY]

No income…………………………..	1
$0-$14,999…...……………………...	2
$15,000-$19,000…………………….	3
$20,000-$24,999…………………….	4
$25,000-$29,999…………………….	5
$30,000-$34,999…………………….	6
$35,000-$39,000	7
$45,000 to $49,999	8
$50,000 or more	9
Refused to answer	10

13. How do you typically pay for your health care? [READ LIST IF NECESSARY]

Private Insurance (HMO, PPO, etc)	1
Medicare	2	Max 3 per group
Medicaid	3
State Assistance	4
Self Pay	5
Refused to answer	6

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

[READ LIST IF NECESSARY]

Primary or Middle School (grade school)	1
Some high school, but not a graduate	2
High school graduate (or GED)	3
Some college/technical, not graduate	4
College graduate or higher	5	2-3 per group

Closing for Ineligible Participants:

Thank you for answering all of my questions. While there are no right or wrong answers, you do not fit the profile of the subjects needed for this focus group study. You are therefore not eligible to be in this study. We value your time and willingness to participate in this research study. Thank you for being willing to help us.

Invitation for Eligible Participants:

Thank you for answering all of my questions. As I mentioned earlier, we are talking to patients and caregivers and we would like to include your opinions in our research study. We would like to invite you to take part in focus group that will last about 90 minutes. You will not be asked to buy anything. You will be contacted at a later date to remind you of the focus group. Any information that you provide to us will be kept confidential to the extent permitted by law. We're simply interested in your opinions.

For participating in the focus group, you will receive $75 as a token of our appreciation.

We will be audiotaping the focus group and some project staff may be observing the focus group and taking notes. As I said, if you choose to attend, whatever you say will be kept private to the extent permitted by law. We will never link your name with any comment you make in the focus group in any report that we write.

If you need to wear glasses either for reading or watching TV, please bring them with you to the focus group.

Also, we need to let you know that there will not be any childcare provided at the facility, so please make the appropriate childcare arrangements if you have children.

Will you be able to join us for a focus group?

Yes	1
No (Refuse to participate)	2	[THANK AND END]

3