Site Visit Recruitment and Scheduling Worksheet

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Community (city and state):

Tribal Affiliation:

Name of Site Visit Facilitator:

Site Visit Recruitment and Scheduling Worksheet

Public reporting burden of this collection of information is estimated to average 3 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining 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 NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)

Please use these screeners to help you identify and schedule people to participate in the Eagle Books Site Visit. There is one scheduling sheet for each type of respondent needed. As you schedule participants, you will need to email or fax a copy of the scheduling sheet to Vernita Branom, at Westat, so we can monitor scheduling and provide assistance where needed. For privacy reasons, please DO NOT include the names of anyone you recruit when you send this grid to Westat. You should keep names and contact for your records only. If you have any questions, please contact Vernita Branom, the Westat site visit coordinator, at [insert toll free number] or [email protected].

Community Representatives : We would like to talk to 3 community representatives who, as part of their job, are working to prevent diabetes and have used the Eagle Books as part of their work. Examples are community health workers, nurses, nutritionists, tribal diabetes educators, people who work at the local IHS clinic or public health clinic, etc. Community representatives MUST work in the tribal community and part of their work MUST include using the Eagle Books. Questions? Call Vernita Branom at [insert #]
Respondent 1	Job Location: Job Title/Role:	VERIFY: Familiar with the Eagle Books Yes No (EXCLUDE) Have used the Eagle Books as a part of their work Yes No (EXCLUDE)	Dates/Times Available: What days & times would work best for you to do a 60 minute interview?
			Scheduling (give each community rep the Community Representative Informational Sheet) Thank you for agreeing to be interviewed. The interview will be held on [insert date, time, location] and will last about an hour. Confirmation (please contact the day BEFORE and the day OF the interview): I am calling to confirm that you are still available for the Eagle Books interview on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Community Representatives : We would like to talk to 3 community representatives who, as part of their job, are working to prevent diabetes and have used the Eagle Books as part of their work. Examples are community health workers, nurses, nutritionists, tribal diabetes educators, people who work at the local IHS clinic or public health clinic, etc. Community representatives MUST work in the tribal community and part of their work MUST include using the Eagle Books. Questions? Call Vernita Branom at [insert #]
Respondent 2	Job Location: Job Title/Role:	VERIFY: Familiar with the Eagle Books Yes No (EXCLUDE) Have used the Eagle Books as a part of their work Yes No (EXCLUDE)	Dates/Times Available: What days & times would work best for you to do a 60 minute interview?
			Scheduling (give each community rep the Community Representative Informational Sheet) Thank you for agreeing to be interviewed. The interview will be held on [insert date, time, location] and will last about an hour. Confirmation (please contact the day BEFORE and the day OF the interview): I am calling to confirm that you are still available for the Eagle Books interview on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Community Representatives : We would like to talk to 3 community representatives who, as part of their job, are working to prevent diabetes and have used the Eagle Books as part of their work. Examples are community health workers, nurses, nutritionists, tribal diabetes educators, people who work at the local IHS clinic or public health clinic, etc. Community representatives MUST work in the tribal community and part of their work MUST include using the Eagle Books. Questions? Call Vernita Branom at [insert #]
Respondent 3	Job Location: Job Title/Role:	VERIFY: Familiar with the Eagle Books Yes No (EXCLUDE) Have used the Eagle Books as a part of their work Yes No (EXCLUDE)	Dates/Times Available: What days & times would work best for you to do a 60 minute interview?
			Scheduling (give each community rep the Community Representative Informational Sheet) Thank you for agreeing to be interviewed. The interview will be held on [insert date, time, location] and will last about an hour. Confirmation (please contact the day BEFORE and the day OF the interview): I am calling to confirm that you are still available for the Eagle Books interview on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

School Administrator: The school MUST be located in or near the tribal community and teach children from the community. The school administrator (principal or assistant principal) MUST be from the same school as the teachers being recruited. The school must have experience using the Eagle Books. Questions? Call Vernita Branom at [insert #]
Name of School:
Respondent 1	Job Title/Role:	VERIFY Eagle Books have been used by teachers at the school Yes No [EXCLUDE]	Dates/Times Available: Before School (insert time______________) Lunch (insert time_____________) After school (insert time_______________)
			Scheduling (give the principal the Teachers/Adminisrator Informational Sheet) Thank you so much for agreeing to take part in the Eagle Books interview. The discussion will be held on [insert date, time, location] and will last about 60 minutes. Confirmation (please contact the day BEFORE and the day OF the group): Hello. I am calling to confirm that you are participating in the Eagle Books interview [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Teachers: We would like to talk to 4 teachers (grades Kindergarten, 1st, 2nd, 3rd, or 4th from the same school as the principal being recruited) who have been using the Eagle Books in their classrooms. The school MUST be located in or near the tribal community and teach children from the community. Teachers MUST have experience using the Eagle Books in their classroom. Questions? Call Vernita Branom at [insert #]
Name of School:
Respondent 1	VERIFY Grade Currently Teaching K 1 2 3 4 Other (________) [EXCLUDE IF NOT A K, 1, 2, 3, OR 4 TEACHER]	VERIFY Have use Eagle Books in their classroom Yes No [EXCLUDE]	Dates/Times Available: Before School (insert time______________) Lunch (insert time_____________) After school (insert time_______________)
			Scheduling (give each teacher recruited the Teacher Informational Sheet) Thank you so much for agreeing to take part in the Eagle Books discussion group. The discussion will be held on [insert date, time, location] and will last about 75 minutes. Confirmation (please contact the day BEFORE and the day OF the group): Hello. I am calling to confirm that you will be attending the Eagle Books Teacher Discussion group on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Teachers: We would like to talk to 4 teachers (grades Kindergarten, 1st, 2nd, 3rd, or 4th from the same school as the principal being recruited) who have been using the Eagle Books in their classrooms. The school MUST be located in or near the tribal community and teach children from the community. Teachers MUST have experience using the Eagle Books in their classroom. Questions? Call Vernita Branom at [insert #]
Name of School:
Respondent 2	VERIFY Grade Currently Teaching K 1 2 3 4 Other (________) [EXCLUDE IF NOT A K, 1, 2, 3, OR 4 TEACHER]	VERIFY Have use Eagle Books in their classroom Yes No [EXCLUDE]	Dates/Times Available: Before School (insert time______________) Lunch (insert time_____________) After school (insert time_______________)
			Scheduling (give each teacher recruited the Teacher Informational Sheet) Thank you so much for agreeing to take part in the Eagle Books discussion group. The discussion will be held on [insert date, time, location] and will last about 75 minutes. Confirmation (please contact the day BEFORE and the day OF the group): Hello. I am calling to confirm that you will be attending the Eagle Books Teacher Discussion group on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Teachers: We would like to talk to 4 teachers (grades Kindergarten, 1st, 2nd, 3rd, or 4th from the same school as the principal being recruited) who have been using the Eagle Books in their classrooms. The school MUST be located in or near the tribal community and teach children from the community. Teachers MUST have experience using the Eagle Books in their classroom. Questions? Call Vernita Branom at [insert #]
Name of School:
Respondent 3	VERIFY Grade Currently Teaching K 1 2 3 4 Other (________) [EXCLUDE IF NOT A K, 1, 2, 3, OR 4 TEACHER]	VERIFY Have use Eagle Books in their classroom Yes No [EXCLUDE]	Dates/Times Available: Before School (insert time______________) Lunch (insert time_____________) After school (insert time_______________)
			Scheduling (give each teacher recruited the Teacher Informational Sheet) Thank you so much for agreeing to take part in the Eagle Books discussion group. The discussion will be held on [insert date, time, location] and will last about 75 minutes. Confirmation (please contact the day BEFORE and the day OF the group): Hello. I am calling to confirm that you will be attending the Eagle Books Teacher Discussion group on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Teachers: We would like to talk to 4 teachers (grades Kindergarten, 1st, 2nd, 3rd, or 4th from the same school as the principal being recruited) who have been using the Eagle Books in their classrooms. The school MUST be located in or near the tribal community and teach children from the community. Teachers MUST have experience using the Eagle Books in their classroom. Questions? Call Vernita Branom at [insert #]
Name of School:
Respondent 4	VERIFY Grade Currently Teaching K 1 2 3 4 Other (________) [EXCLUDE IF NOT A K, 1, 2, 3, OR 4 TEACHER]	VERIFY Have use Eagle Books in their classroom Yes No [EXCLUDE]	Dates/Times Available: Before School (insert time______________) Lunch (insert time_____________) After school (insert time_______________)
			Scheduling (give each teacher recruited the Teacher Informational Sheet) Thank you so much for agreeing to take part in the Eagle Books discussion group. The discussion will be held on [insert date, time, location] and will last about 75 minutes. Confirmation (please contact the day BEFORE and the day OF the group): Hello. I am calling to confirm that you will be attending the Eagle Books Teacher Discussion group on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Parents/Guardians (Kindergarten and 1st Grade): We would like to talk to 4 parents/guardians of children in Kindergarten of 1st grade (and their child) living in or near the community. Their children MUST attend the elementary school from which the principal and teachers are being recruited. Parents MUST have some experience or familiarity with the Eagle Books. The parent discussion group AND child group will take place at the same time, in the same location. Questions? Call Vernita Branom at [insert #]
Respondent 1	VERIFY Tribal Affiliation (IF ANY): School Child Attends: Age of Child: Current Grade: K 1 [EXCLUDE IF CHILD NOT IN K or 1]	VERIFY Are familiar with the Eagle Books (have read the Books or seen the Books) Yes No [EXCLUDE]	Dates/Times Available:
			Scheduling (give each parent the Parent Informational Sheet) Thank you so much for agreeing to take part in the Eagle Books discussion group. The discussion will be held on [insert date, time, location] and will last about an hour. Confirmation (please contact the day BEFORE and the day OF the group): Hello. I am calling to confirm that you will be attending the Eagle Books parent group on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Parents/Guardians (Kindergarten and 1st Grade): We would like to talk to 4 parents/guardians of children in Kindergarten of 1st grade (and their child) living in or near the community. Their children MUST attend the elementary school from which the principal and teachers are being recruited. Parents MUST have some experience or familiarity with the Eagle Books. The parent discussion group AND child group will take place at the same time, in the same location. Questions? Call Vernita Branom at [insert #]
Respondent 2	VERIFY Tribal Affiliation (IF ANY): School Child Attends: Age of Child: Current Grade: K 1 [EXCLUDE IF CHILD NOT IN K or 1]	VERIFY Are familiar with the Eagle Books (have read the Books or seen the Books) Yes No [EXCLUDE]	Dates/Times Available:
			Scheduling (give each parent the Parent Informational Sheet) Thank you so much for agreeing to take part in the Eagle Books discussion group. The discussion will be held on [insert date, time, location] and will last about an hour. Confirmation (please contact the day BEFORE and the day OF the group): Hello. I am calling to confirm that you will be attending the Eagle Books parent group on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Parents/Guardians (Kindergarten and 1st Grade): We would like to talk to 4 parents/guardians of children in Kindergarten of 1st grade (and their child) living in or near the community. Their children MUST attend the elementary school from which the principal and teachers are being recruited. Parents MUST have some experience or familiarity with the Eagle Books. The parent discussion group AND child group will take place at the same time, in the same location. Questions? Call Vernita Branom at [insert #]
Respondent 3	VERIFY Tribal Affiliation (IF ANY): School Child Attends: Age of Child: Current Grade: K 1 [EXCLUDE IF CHILD NOT IN K or 1]	VERIFY Are familiar with the Eagle Books (have read the Books or seen the Books) Yes No [EXCLUDE]	Dates/Times Available:
			Scheduling (give each parent the Parent Informational Sheet) Thank you so much for agreeing to take part in the Eagle Books discussion group. The discussion will be held on [insert date, time, location] and will last about an hour. Confirmation (please contact the day BEFORE and the day OF the group): Hello. I am calling to confirm that you will be attending the Eagle Books parent group on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Parents/Guardians (Kindergarten and 1st Grade): We would like to talk to 4 parents/guardians of children in Kindergarten of 1st grade (and their child) living in or near the community. Their children MUST attend the elementary school from which the principal and teachers are being recruited. Parents MUST have some experience or familiarity with the Eagle Books. The parent discussion group AND child group will take place at the same time, in the same location. Questions? Call Vernita Branom at [insert #]
Respondent 4	VERIFY Tribal Affiliation (IF ANY): School Child Attends: Age of Child: Current Grade: K 1 [EXCLUDE IF CHILD NOT IN K or 1]	VERIFY Are familiar with the Eagle Books (have read the Books or seen the Books) Yes No [EXCLUDE]	Dates/Times Available:
			Scheduling (give each parent the Parent Informational Sheet) Thank you so much for agreeing to take part in the Eagle Books discussion group. The discussion will be held on [insert date, time, location] and will last about an hour. Confirmation (please contact the day BEFORE and the day OF the group): Hello. I am calling to confirm that you will be attending the Eagle Books parent group on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Parents/Guardians (2nd, 3rd, 4th grade): We would like to talk to 4 parents/guardians of children in 2nd, 3rd, or 4th (and their child) living in or near the community. Their children MUST attend the elementary school from which the principal and teachers are being recruited. Parents MUST have some experience or familiarity with the Eagle Books. The parent discussion group AND child group will take place at the same time, in the same location. Questions? Call Vernita Branom at [insert #]
Respondent 1	VERIFY Tribal Affiliation (IF ANY): School Child Attends: Age of Child: Current Grade: 2 3 4 [EXCLUDE IF CHILD NOT IN 2, 3, or 4]	VERIFY Are familiar with the Eagle Books (have read the Books or seen the Books) Yes No [EXCLUDE]	Dates/Times Available:
			Scheduling (give each parent the Parent Informational Sheet) Thank you so much for agreeing to take part in the Eagle Books discussion group. The discussion will be held on [insert date, time, location] and will last about an hour. Confirmation (please contact the day BEFORE and the day OF the group): Hello. I am calling to confirm that you will be attending the Eagle Books parent group on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Parents/Guardians (2nd, 3rd, 4th grade): We would like to talk to 4 parents/guardians of children in 2nd, 3rd, or 4th (and their child) living in or near the community. Their children MUST attend the elementary school from which the principal and teachers are being recruited. Parents MUST have some experience or familiarity with the Eagle Books. The parent discussion group AND child group will take place at the same time, in the same location. Questions? Call Vernita Branom at [insert #]
Respondent 2	VERIFY Tribal Affiliation (IF ANY): School Child Attends: Age of Child: Current Grade: 2 3 4 [EXCLUDE IF CHILD NOT IN 2, 3, or 4]	VERIFY Are familiar with the Eagle Books (have read the Books or seen the Books) Yes No [EXCLUDE]	Dates/Times Available:
			Scheduling (give each parent the Parent Informational Sheet) Thank you so much for agreeing to take part in the Eagle Books discussion group. The discussion will be held on [insert date, time, location] and will last about an hour. Confirmation (please contact the day BEFORE and the day OF the group): Hello. I am calling to confirm that you will be attending the Eagle Books parent group on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Parents/Guardians (2nd, 3rd, 4th grade): We would like to talk to 4 parents/guardians of children in 2nd, 3rd, or 4th (and their child) living in or near the community. Their children MUST attend the elementary school from which the principal and teachers are being recruited. Parents MUST have some experience or familiarity with the Eagle Books. The parent discussion group AND child group will take place at the same time, in the same location. Questions? Call Vernita Branom at [insert #]
Respondent 3	VERIFY Tribal Affiliation (IF ANY): School Child Attends: Age of Child: Current Grade: 2 3 4 [EXCLUDE IF CHILD NOT IN 2, 3, or 4]	VERIFY Are familiar with the Eagle Books (have read the Books or seen the Books) Yes No [EXCLUDE]	Dates/Times Available:
			Scheduling (give each parent the Parent Informational Sheet) Thank you so much for agreeing to take part in the Eagle Books discussion group. The discussion will be held on [insert date, time, location] and will last about an hour. Confirmation (please contact the day BEFORE and the day OF the group): Hello. I am calling to confirm that you will be attending the Eagle Books parent group on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Parents/Guardians (2nd, 3rd, 4th grade): We would like to talk to 4 parents/guardians of children in 2nd, 3rd, or 4th (and their child) living in or near the community. Their children MUST attend the elementary school from which the principal and teachers are being recruited. Parents MUST have some experience or familiarity with the Eagle Books. The parent discussion group AND child group will take place at the same time, in the same location. Questions? Call Vernita Branom at [insert #]
Respondent 4	VERIFY Tribal Affiliation (IF ANY): School Child Attends: Age of Child: Current Grade: 2 3 4 [EXCLUDE IF CHILD NOT IN 2, 3, or 4]	VERIFY Are familiar with the Eagle Books (have read the Books or seen the Books) Yes No [EXCLUDE]	Dates/Times Available:
			Scheduling (give each parent the Parent Informational Sheet) Thank you so much for agreeing to take part in the Eagle Books discussion group. The discussion will be held on [insert date, time, location] and will last about an hour. Confirmation (please contact the day BEFORE and the day OF the group): Hello. I am calling to confirm that you will be attending the Eagle Books parent group on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Middle Schoolers (children ages 11 through 14): We would like to talk to 4 children attending middle school or junior high, in or near the community. Questions? Call Vernita Branom at [insert #]
Respondent 1	VERIFY Tribal Affiliation (IF ANY): Age of Child: Current Grade: 6 7 8 9 [EXCLUDE IF CHILD NOT IN 6, 7, 8, or 9th grade]	Dates/Times Available:
		Scheduling (give each parent the Middle School and Parent Informational Sheet) Thank you so much for agreeing to take part in the middle school discussion group. The discussion will be held on [insert date, time, location] and will last about an hour. Confirmation (please contact the day BEFORE and the day OF the group): Hello. I am calling to confirm that you will be attending the middle school group on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Middle Schoolers (children ages 11 through 14): We would like to talk to 4 children attending middle school or junior high, in or near the community. Questions? Call Vernita Branom at [insert #]
Respondent 2	VERIFY Tribal Affiliation (IF ANY): Age of Child: Current Grade: 6 7 8 9 [EXCLUDE IF CHILD NOT IN 6, 7, 8, or 9th grade]	Dates/Times Available:
		Scheduling (give each parent the Middle School and Parent Informational Sheet) Thank you so much for agreeing to take part in the middle school discussion group. The discussion will be held on [insert date, time, location] and will last about an hour. Confirmation (please contact the day BEFORE and the day OF the group): Hello. I am calling to confirm that you will be attending the middle school group on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Middle Schoolers (children ages 11 through 14): We would like to talk to 4 children attending middle school or junior high, in or near the community. Questions? Call Vernita Branom at [insert #]
Respondent 3	VERIFY Tribal Affiliation (IF ANY): Age of Child: Current Grade: 6 7 8 9 [EXCLUDE IF CHILD NOT IN 6, 7, 8, or 9th grade]	Dates/Times Available:
		Scheduling (give each parent the Middle School and Parent Informational Sheet) Thank you so much for agreeing to take part in the middle school discussion group. The discussion will be held on [insert date, time, location] and will last about an hour. Confirmation (please contact the day BEFORE and the day OF the group): Hello. I am calling to confirm that you will be attending the middle school group on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)

Middle Schoolers (children ages 11 through 14): We would like to talk to 4 children attending middle school or junior high, in or near the community. Questions? Call Vernita Branom at [insert #]
Respondent 4	VERIFY Tribal Affiliation (IF ANY): Age of Child: Current Grade: 6 7 8 9 [EXCLUDE IF CHILD NOT IN 6, 7, 8, or 9th grade]	Dates/Times Available:
		Scheduling (give each parent the Middle School and Parent Informational Sheet) Thank you so much for agreeing to take part in the middle school discussion group. The discussion will be held on [insert date, time, location] and will last about an hour. Confirmation (please contact the day BEFORE and the day OF the group): Hello. I am calling to confirm that you will be attending the middle school group on [insert date, time, location]. Can you still make it? Yes No (let Westat know immediately)