Participant Screener - Adults 25-64 Recently Hospitalize

PARTICIPANT SCREENER

(Adults (25-64) recently hospitalized)

Criteria for focus group:

• 8-9 participants per focus group, recruit 11

• Separate groups by gender

• Ages 25-64

• No family history or stroke or DVT

• Any race/ethnicity but some diversity in groups

• High School Grad or higher

• Childbirth, fracture, surgery, injury, or cancer treatment –OR–

• Hospital stay in the last 12 months

NOTES TO FACILITY

• Please do not call people with medical or health-related occupations

• Please do not call people who have done a focus group in the last 6 months.

• Please do not call people who have ever done 5 or more focus groups.

Hello. My name is _____ of _______, a local marketing research firm. We are recruiting participants for a research study. Participants in this study will receive $75. Let me assure you that this is a legitimate research study. I am not trying to sell anything. I have just a couple of questions to see if you qualify for the study.

1. RECORD GENDER

( ) Female – CONTINUE. [SEPARATE GROUPS BY GENDER]

( ) Male – CONTINUE. [SEPARATE GROUPS BY GENDER]

2. Please stop me when I mention the group that includes your age.

( ) 18 – 24 – THANK & TERMINATE.

( ) 25 – 29 – CONTINUE.

( ) 30 – 39 – CONTINUE.

( ) 40 – 49 – CONTINUE.

( ) 50 – 64 – CONTINUE.

( ) 65 – 74 – THANK & TERMINATE.

( ) 75 – 84 – THANK & TERMINATE.

( ) 85 and older – THANK & TERMINATE.

( ) Refused – THANK & TERMINATE.

3. . Are you: [RECRUIT A MIX]

( ) Married

( ) Never married

( ) Divorced or separated

( ) Widowed

( ) Partnered (or living with a domestic partner)

( ) Refused – THANK & TERMINATE.

4. In the past 12 months, have you had any of the following medical conditions?

		YES	NO
A	[WOMEN ONLY] Childbirth?	 CONTINUE	 CONTINUE
B	Fracture or broken bones?	 CONTINUE	 CONTINUE
C	Surgery?	 CONTINUE	 CONTINUE
D	An injury or accident that required a hospital stay?	 CONTINUE	 CONTINUE
E	Cancer treatment?	 CONTINUE	 CONTINUE

5. In the past 12 months, have you had a hospital stay of 3 or more days?

( ) Yes – CONTINUE

( ) No – CONTINUE

( ) Refused – THANK & TERMINATE

6. Do you currently smoke cigarettes?

( ) Yes – CONTINUE

( ) No – CONTINUE

( ) Refused – THANK & TERMINATE

7. Have you or a close family member ever had any of the following medical conditions?

		YES	NO
A	Stroke	 THANK & TERMINATE	 CONTINUE
B	High blood pressure	 CONTINUE	 CONTINUE
C	Deep vein thrombosis, or DVT	 THANK & TERMINATE	 CONTINUE
D	Hemophilia	 CONTINUE	 CONTINUE
E	Sickle cell disease	 CONTINUE	 CONTINUE

8. What is the last year of school or college you have completed?

( ) Less than High School – THANK & TERMINATE

( ) High School grad – CONTINUE

( ) Some college – CONTINUE

( ) 4-year college graduate – CONTINUE

( ) Graduate school – CONTINUE

( ) Refused – THANK & TERMINATE

9. What is your race/ethnicity?

Ethnicity:

( ) Hispanic Origin

( ) Not of Hispanic Origin

( ) Refused to answer

Race:

( ) American Indian or Alaska Native

( ) Asian

( ) Hawaiian or other Pacific Islander

( ) Black or African American - – [RECRUIT AT LEAST 2]

( ) White or Caucasian – [RECRUIT AT LEAST 2]

( ) Refused – THANK & TERMINATE.

10. Are you currently employed?

( ) Yes

( ) No – [RECRUIT 3 MAXIMUM]

11. Do you have any difficulty reading in English?

( ) Yes – THANK & TERMINATE.

( ) No

12. Finally, do you or anyone in your household work for an advertising agency, marketing or marketing research firm, or in any business, organization or agency involved in health or healthcare?

( ) Yes – THANK & TERMINATE.

( ) No

READ THE FOLLOWING:

I’d like to invite you to take part in a research study that takes the form of a group discussion. The discussion will be held on XXXXX and will last about 90 minutes. No one will try to sell you anything in this discussion and no one will contact you for any sales purpose as a result of your participation in this study. We are only interested in your opinions and, as I mentioned earlier, you will receive $75 for taking part in this study. If you arrive 15 minutes before the start of the group, you will be entered into an early bird lottery for an additional $50.

If you need them, please remember to bring your reading glasses.

( ) TIME = NON MEALTIMES. Refreshments will be served.

( ) TIME = MEALTIMES. A light dinner will be served.

GIVE RESPONDENT DIRECTIONS TO FACILITY. We will call you the day before to remind you about this discussion. We will be counting on your attendance since we will only be inviting about ten people. So that we can be sure to start and end on time, please plan to arrive at our office fifteen minutes before the beginning of the group. We are counting on your participation, so please be sure to contact us as soon as possible if something arises and you find you can’t attend.

May I please get your:

Name: _________________________________________________________________________

Address: ________________________________ City:_________________ Zip: _____________

Home Phone: ___________________________ Work Phone: _____________________________

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