Form CMS-10360 Screener_Healthcare Patient Consumers

Screener: Healthcare Patient Consumers
Target Population:
Group A - Consumers who have had a hospital stay within the past 6 months
Group B - Consumers who anticipate a hospital stay within the next 6 months
Recruitment Criteria:
Ages 40-70
All participants should regularly use the Internet (at least four times per week)
Exclude individuals who currently work or previously worked in the health care industry
or who have an immediate family member who is currently working in the health care
industry.
Exclude individuals who are current or former employees of the Social Security
Administration or the Department of Health and Human Services or one of its related
agencies (such as the Centers for Medicare & Medicaid Services, the Health Care
Financing Administration, the Agency for Healthcare Research and Quality, the Centers
for Disease Control, the Food and Drug Administration)
Exclude individuals who have participated in a health or health insurance related IDI or
focus group within the past year and/or who have participated in an IDI or focus group
within the past 6 months.
Recruitment Mix:
Recruit approximately 50% female and 50% male
Recruit a mix of race/ethnicity (Caucasian vs. Non-Caucasian)
Recruit a mix of education level (less than high school, high school graduate/GED, some
college, college graduate, post graduate). No more than 8 recruits of the 12 should have
education higher than a high-school diploma. (i.e. Some College/Associates, Bachelors, or
higher.)

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INTRODUCTION
Hello, my name is _____________ from ______________, a local research firm here in the
____________ area. We are working with L&M Policy Research on a project about health care.
If needed: If recruit asks about L&M Policy Research, please say the following: “L&M
Policy Research is a company with headquarters in Washington, D.C that conducts
research on many different healthcare issues.”
I’m calling today about a project that we are doing about the quality of certain hospital services
for the Centers for Medicare & Medicaid Services, the federal government agency that runs
Medicare. For this study we’d like your help figuring out the clearest way to tell people about
this hospital information. If you are interested in helping with the project and you meet its
requirements, we will invite you to come for an interview on [TBD]. It would take about 90
minutes of your time, and we would pay you [$XX] at the end of the interview. May I ask you a
few questions to see if you qualify to participate? If yes, continue to #1. If no, thank and end.
If needed: Since we need to include people who are a mix of different backgrounds and
experiences, there are some requirements that I have to check on for all of the people that
we bring in to participate. I need to ask you a few questions to see if you meet the
requirements for participating in the discussion.

1. Are you currently working or have you ever worked in the health care industry? (e.g.,
working for a hospital, nursing home, pharmacy, home health agency, medical office, clinic,
diagnostic imaging center, health plan, HMO, health insurance company, or pharmaceutical
company)
____ YES → Thank and end call
____ NO → Continue
____ NOT SURE → Thank and end call

2. Is an immediate family member currently working in the health care industry? (e.g.,
working for a hospital, nursing home, pharmacy, home health agency, medical office, clinic,
diagnostic imaging center, health plan, HMO, health insurance company, or pharmaceutical
company)
____ YES → Thank and end call
____ NO → Continue
____ NOT SURE → Thank and end call
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3. Are you currently or have you ever been employed by the Social Security
Administration or the Department of Health and Human Services or one of its related
agencies, such as the Centers for Medicare & Medicaid Services, the Health Care
Financing Administration, the Agency for Healthcare Research and Quality, the
Centers for Disease Control, or the Food and Drug Administration?
____ YES → Thank and end call
____ NO → Continue
4. Have you been paid to participate in an interview, focus group, or other group or
individual discussion in the past 6 months?
____ YES → Thank and end call
____ NO → Continue
____ NOT SURE → Thank and end call

5. Have you been paid to participate in a health or health insurance related interview,
focus group, or other individual or group discussion in the past year?
____ YES → Thank and end call
____ NO → Continue
____ NOT SURE → Thank and end call

6. Which category best describes your age? {Read list below.} {RECRUIT MIX}
____ 39 or younger→ Thank and end call
____ 40 – 49 → Continue
____ 50 – 59 → Continue
____ 60 – 70 → Continue
____ 71 or older → Thank and end call

7. Have you visited Web sites on the Internet?
____ YES → Continue
____ NO → Thank and end call

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8. How often do you use the Internet for things other than for checking e-mail (e.g., for
things such as checking news, online shopping, or searching for information)?
____ At least once per day → Continue
____ At least four times per week → Continue
____ About twice per week → Continue
____ About once per week → Thank and end call
____ Twice per month or less frequently → Thank and end call

9. If you were looking to make a major purchase (i.e. shopping for a car, a computer, or
any other major purchase), which of the following sources would you use for
researching and comparing items before purchasing? {Read EVERY item and check ALL
that apply.}
____ Friends and family → Continue
____ Trade magazines or literature (Car and Driver, Consumer Reports, etc.) → Continue
____ Internet (blue book, AAA) → Continue
____ Other → Continue

10. If you were looking for information to find a hospital for a planned health care service
or procedure, which of the following sources would you use? {Read EVERY item and
check ALL that apply.}
____ Friends and family → Continue
____ Magazines or other literature (US News & World Report, etc.) → Continue
____ Internet (hospital websites) → Continue
____ Other → Continue

11. Have you been admitted to a hospital in the last 6 months?
____ Yes → Continue (Recruit for Group A)
____ No → Continue/skip to12

12. Do you anticipate being admitted to a hospital in the next 6 months?
____ Yes → Continue (Recruit for Group B)
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____ No → Thank and end call
I have a few more questions about your background. Again, this information will enable us
to make sure we have a broad mix of people participating in the interviews. If you feel
uncomfortable answering any of these questions, please let me know and we’ll go on to the
next question.
13. Gender. {Confirm if needed.}
____ MALE → Continue {RECRUIT ~50%}
____ FEMALE → Continue {RECRUIT ~50%}
14. What is the last or highest grade that you finished in school? {Do not read options.}
{RECRUIT MIX }
____ Less than high school degree → Continue
____ High school degree or GED→ Continue
____ Some college or two year degree →Continue
____ College graduate/4-year college degree → Continue
____ More than 4-year college degree →Continue

15. Are you of Hispanic or Latino origin or descent?
____ Yes, Hispanic or Latino → Continue
____ No, not Hispanic or Latino → Continue

16. Are you White?
____ Yes, White
____ No, Not White → Continue

17. Are you Black or African-American?
____ Yes, Black or African-American → Continue
____ No, not Black or African-American → Continue

18. Are you Asian?
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____ Yes, Asian → Continue
____ No, not Asian → Continue

19. Are you Native Hawaiian or Other Pacific Islander?
____ Yes, Native Hawaiian or Other Pacific Islander → Continue
____ No, not Native Hawaiian or Other Pacific Islander → Continue

20. Are you American Indian or Alaska Native?
____ Yes, American Indian or Alaska Native → Continue
____ No, not American Indian or Alaska Native → Continue

CONTINUE TO INVITATION BELOW
INVITATION:
Thank you for answering all of my questions. We would like to invite you to participate in the
study that will take place on _________________________ located in ____________________.
The interview will last about 90 minutes. As a thank you for your participation, you will be paid
$XX.

Are you willing to participate?

Yes____(CONTINUE)

No____(THANK/END)

[Schedule date and time]

Now, let me just verify the spelling of your name and your address, so we can send you a
confirmation letter with directions. (RECORD RESPONDENT’S INFORMATION)

Name:_______________________________Telephone:________________________
Email:_______________________________________
Address:_______________________________________________________________
City, State:____________________________________________Zip:__________________
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[IF EMAIL PROVIDED:] Would you rather receive a reminder by email or regular mail?
Email
Regular mail

As I mentioned during our conversation, you will be asked to read and discuss some materials
during the interview. So if you use reading glasses or assistive hearing devices, please remember
to bring them with you.
If you have any questions or find that you can’t attend, please call us right away at
___________________ so that we can find a replacement. Thank you for your time and for
agreeing to help.

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