Participant Re-Screener - Adults 25-64 Recently Hospital

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

PARTICIPANT RE-SCREENER

(Adults (25-64) recently hospitalized)

LOCATION OF GROUP

DATE OF GROUP

1. Name (First name Last initial): ________________________________

2. City/Town of residence: ______________________________________

3. Age: ______

4. Are you:

[CHECK ONE]

( ) Married

( ) Never married

( ) Divorced or separated

( ) Widowed

( ) Living with a domestic partner)

5. How many children under 18
   are in your household? _______

6. What is the last grade of school or college you had the opportunity to complete?

[CHECK ONE]

( ) Less than high school

( ) High school graduate/GED

( ) Some college

( ) 4-year college graduate

( ) Post-graduate degree

7. Are you:

[CHECK ALL THAT APPLY]

( ) Employed full-time

( ) Employed part-time

( ) Unemployed

( ) Retired

( ) Student

8. Occupation (if applicable): _____________________________________________________

9. Name of organization where you work (if applicable): ________________________________

10. Spouse/partner’s occupation (if applicable): _________________________________________

11. How many focus groups have you ever attended? _______

12. What was the subject of those focus groups? ________________________________________

__________________________________________________________________________________

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

[MARK ONE RESPONSE IN EACH ROW]

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

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

( ) Yes

( ) No

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

[MARK ONE RESPONSE IN EACH ROW]

		Yes	No
A	Stroke		
B	High blood pressure		
C	Deep vein thrombosis, or DVT		
D	Hemophilia		

16. What magazines do you regularly read?

1. _____________________________

2. _____________________________

3. _____________________________

17. What TV/radio shows do you regularly go to for your news?

1. _____________________________

2. _____________________________

3. _____________________________

18. What newspapers/websites do you regularly read for your news?

1. _____________________________

2. _____________________________

3. _____________________________

19. In the past year, have you looked for information about a health concern or medical problem?

( ) Yes

( ) No [SKIP Q20]

20. [IF YES IN Q19] Please indicate whether you tried to find health information in the past year from any of the following sources:

[MARK ONE RESPONSE IN EACH ROW]

		Yes	No
A.	Newspaper articles		
B.	General interest magazines		
C.	Health magazines		
D.	Doctor or nurse		
E.	Friends or relatives		
F.	TV or radio		
G.	Internet/World Wide Web		

PLEASE RETURN THIS QUESTIONNAIRE TO YOUR HOST OR HOSTESS.

The public reporting burden of this collection of information is estimated to average 9 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-XXXX)