Telephone Screening Interview for Birth Centers

Form Approved

OMB #0920-0743
Exp. Date: xx/xx/xxxx

Screening Telephone Call to Identify the Appropriate

Survey Respondent at Birth Centers

A screening call will be made to all birth centers from a list provided by the American Association of Birth Centers. The screening calls will (1) confirm that the birth center is eligible for inclusion in the study; (2) determine whether or not the birth center has satellite locations that provide intrapartum care; and (3) obtain the name and address of the individual who is most knowledgeable about infant feeding practices at the birth center. The screening survey will be administered as computer-assisted telephone interview. As a result, data entry will be performed as part of the interview process and the skip-logic will be electronic.

Call #1 to the receptionist who answers the phone at the birth center.

1. Can you please connect me to the Director of the birth center?

Once connected:

Hello. My name is (INTERVIEWER NAME). I am calling on behalf of the Centers for Disease Control and Prevention. CDC is conducting a national survey of Maternity Practices in Infant Nutrition and Care. The survey is being sent to all hospitals and freestanding birth centers in the U.S. and Territories that routinely provide maternity care. I need to first confirm that this birth center provides maternity care.

2. Was this birth center providing maternity care as of December 31, 2010?

• Yes

• No

If NO, conclude the interview by saying: “I’m sorry, but our study is focusing on maternity care. Thank you very much for your time.” If YES, continue with question 3.

Public reporting burden of 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 CDC Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0743). Do not send the completed form to this address.

2. Does this birth center have multiple locations that provide maternity care?

 Yes

• No

If NO, continue with question 6.

If YES, continue with question 4.

2. How many locations provide maternity care?

• one

• two

• three

• four

2. Could you please provide a contact and telephone number for each of the locations?

• Location 1: Telephone number_______________ Contact___________________

• Location 2: Telephone number_______________ Contact___________________

• NA

• Location 3: Telephone number_______________ Contact___________________

• NA

• Location 4: Telephone number_______________ Contact___________________

• NA

2. We will be mailing a survey to your facility. The survey includes questions about infant feeding such as breastfeeding, use of formula by healthy newborns, and feeding routines. I was hoping that you will be able to help me identify the best person to complete the survey. This may be yourself, or another person at the birth center. Please record the name and title of that person identified.

Name: _________________________________________

Title: _________________________________________

2. What is the Federal Express address, telephone number, and email address for [PERSON IDENTIFIED IN QUESTION 6]? Be sure that the address includes the name of the birth center.

Name of birth center: _________________________________________

Address: _________________________________________

_________________________________________

City, State, Zip Code: _________________________________________

Telephone Number: _________________________________________

2. Is the mailing address for Dr./Mr./Ms. [PERSON IDENTIFIED IN QUESTION 6] the same as his/her Federal Express address? If not, what is his/her mailing address?

Mailing address: _________________________________________

_________________________________________

City, State, Zip Code: _________________________________________

Conclude the interview by saying: “That is all the information I need at the moment. Thank you very much for your time and assistance. You have been very helpful. Good-bye.”

Call to additional locations of birth center providing maternity care.

Hello. My name is (INTERVIEWER NAME). I am calling on behalf of the Centers for Disease Control and Prevention. CDC is conducting a national survey of Maternity Practices in Infant Nutrition and Care. The survey is being sent to all hospitals and freestanding birth centers in the U.S. and Territories that routinely provide maternity care. We understand that this facility provides maternity care associated with (BIRTH CENTER IDENTIFIED in Question 7). I need to first confirm that this birth center provides maternity care.

2. Was this birth center providing maternity care as of December 31, 2010?

• Yes

• No

If NO, conclude the interview by saying: “I’m sorry, but our study is focusing on maternity care. Thank you very much for your time.” If YES, continue with question 3.

2. We will be mailing a survey to your facility. The survey includes questions about infant feeding such as breastfeeding, use of formula by healthy newborns, and feeding routines. I was hoping that you will be able to help me identify the best person to complete the survey. This may be yourself, or another person at the birth center. Please record the name and title of that person identified.

Name: _________________________________________

Title: _________________________________________

2. What is the Federal Express address, telephone number, and email address for [PERSON IDENTIFIED IN QUESTION 10]? Be sure that the address includes the name of the birth center.

Name of birth center: _________________________________________

Address: _________________________________________

_________________________________________

City, State, Zip Code: _________________________________________

Telephone Number: _________________________________________

2. Is the mailing address for Dr./Mr./Ms. [PERSON IDENTIFIED IN QUESTION 10] the same as his/her Federal Express address? If not, what is his/her mailing address?

Mailing address: _________________________________________

_________________________________________

City, State, Zip Code: _________________________________________

Conclude the interview by saying: “That is all the information I need at the moment. Thank you very much for your time and assistance. You have been very helpful. Good-bye.”

Telephone Screening Interview – Birth Centers Appendix G-2 page 5 of 5