Appendix M: Respondent Selection Variations
Respondent Selection Version 1: All-Adult Method
OMB # 0925-0538
Expiration Date: XXXXX
STATEMENT
OF CONFIDENTIALITY Collection
of this information is authorized by The Public Health Service Act,
Sections 411 (42 USC 285 a) and 412 (42 USC 285a-1.a and 285a1.3).
Rights of study participants are protected by The Privacy Act of
1974. Participation is voluntary, and there are no penalties for not
participating or withdrawing from the study at any time. Refusal to
participate will not affect your benefits in any way. The
information collected in this study will be kept private under the
Privacy Act and will only be seen by people authorized to work on
this project. The report summarizing the findings will not contain
any names or identifying information. Identifying information will
be destroyed when the project ends. NOTIFICATION
TO RESPONDENT OF ESTIMATED BURDEN Public
reporting burden for this collection of information is estimated to
average 30
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: NIH, Project Clearance Branch, 6705 Rockledge Drive,
MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0589). Do not
return the completed form to this address.
START HERE:
How many adults age 18 or older live in this household?
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Each adult (age 18 or older) living in your household should fill out one questionnaire. Please be sure that each adult has an opportunity to fill out a questionnaire. This is very important to the success of the study.
If more questionnaires are needed, please call 1-888-xxx-xxxx
Not all questions will apply to you – sometimes you will see instructions following your answer to a question that direct you to skip to a question farther in the questionnaire.
Si prefiere recibir la encuesta en Español, por favor llame 1-888-XXX-XXXX.
Respondent Selection Version 2: Next Birthday Method
OMB # 0925-0538
Expiration Date: XXXXX
STATEMENT
OF CONFIDENTIALITY Collection
of this information is authorized by The Public Health Service Act,
Sections 411 (42 USC 285 a) and 412 (42 USC 285a-1.a and 285a1.3).
Rights of study participants are protected by The Privacy Act of
1974. Participation is voluntary, and there are no penalties for not
participating or withdrawing from the study at any time. Refusal to
participate will not affect your benefits in any way. The
information collected in this study will be kept private under the
Privacy Act and will only be seen by people authorized to work on
this project. The report summarizing the findings will not contain
any names or identifying information. Identifying information will
be destroyed when the project ends. NOTIFICATION
TO RESPONDENT OF ESTIMATED BURDEN Public
reporting burden for this collection of information is estimated to
average 30
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: NIH, Project Clearance Branch, 6705 Rockledge Drive,
MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0589). Do not
return the completed form to this address.
START HERE:
How many adults age 18 or older live in this household?
|
|
WHO SHOULD COMPLETE THIS QUESTIONNAIRE:
If more than one adult lives here, then the adult with the next birthday should complete this questionnaire. If only one adult lives here, then that adult should complete this questionnaire.
Please write the first name, nickname or initials of the adult with the next birthday. This is the person who should complete this questionnaire.
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First name, nickname or initials
If more questionnaires are needed, please call 1-888-xxx-xxxx
Not all questions will apply to you – sometimes you will see instructions following your answer to a question that direct you to skip to a question farther in the questionnaire.
Si prefiere recibir la encuesta en Español, por favor llame 1-888-XXX-XXXX.
Respondent Selection Version 3: Hagan-Collier Method
OMB # 0925-0538
Expiration Date: XXXXX
STATEMENT
OF CONFIDENTIALITY Collection
of this information is authorized by The Public Health Service Act,
Sections 411 (42 USC 285 a) and 412 (42 USC 285a-1.a and 285a1.3).
Rights of study participants are protected by The Privacy Act of
1974. Participation is voluntary, and there are no penalties for not
participating or withdrawing from the study at any time. Refusal to
participate will not affect your benefits in any way. The
information collected in this study will be kept private under the
Privacy Act and will only be seen by people authorized to work on
this project. The report summarizing the findings will not contain
any names or identifying information. Identifying information will
be destroyed when the project ends. NOTIFICATION
TO RESPONDENT OF ESTIMATED BURDEN Public
reporting burden for this collection of information is estimated to
average 30
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: NIH, Project Clearance Branch, 6705 Rockledge Drive,
MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0589). Do not
return the completed form to this address.
START HERE:
How many adults age 18 or older live in this household?
|
|
In order for the study to accurately represent all adults in America, we are asking households to have the person fitting the rule shown below complete this questionnaire. Following this rule is very important to the success of the study. Thank you for your cooperation.
WHO SHOULD COMPLETE THIS QUESTIONNAIRE: (only one will display per questionnaire)
The oldest adult male in the household should complete this questionnaire. If no males live here, then the oldest adult female in the household should complete this questionnaire.
The oldest adult female in the household should complete this questionnaire. If no females live here, then the oldest adult male in the household should complete this questionnaire.
The youngest adult male in the household should complete this questionnaire. If no males live here, then the youngest adult female in the household should complete this questionnaire.
The youngest adult female in the household should complete this questionnaire. If no females live here, then the youngest adult male in the household should complete this questionnaire.
Please write the first name, nickname or initials of the (oldest/youngest) adult (male/female) living here. This is the person who should complete this questionnaire. (This language will match the rule used.)
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|
|
|
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First name, nickname or initials
If more questionnaires are needed, please call 1-888-xxx-xxxx
Not all questions will apply to you – sometimes you will see instructions following your answer to a question that direct you to skip to a question farther in the questionnaire.
Si prefiere recibir la encuesta en Español, por favor llame 1-888-XXX-XXXX.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Terisa Davis - Health Studies |
| File Modified | 0000-00-00 |
| File Created | 2021-02-01 |