Form 1 Screener_Life

_{Attachment 1: Screener for the NCI "Life in a Day" Phone App Study}

OMB No. 0925-0642

Expiry Date: 09/30/2014

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_INTRO

NAME

_PHONE

RESPONDENT NUMBER _

Hello, my name is (NAME) and I'm calling from Westat, a research company in Rockville. May I speak with (NAME)? (Reintroduce yourself if needed)

Thank you for your interest in the Life in A Day Phone Application Study. I would like to tell you a little bit about the study and then I' II ask you a few questions to see if you are eligible to take part.

We are testing a phone application that allows you to track your daily activities. We're looking for people to participate in this research study, which would take an hour or so on the first and third days of this study:

• On the first day, you would need to come to Westat for one 60 minute in-person session where a researcher will get you acquainted with the application on the phone that you will use for this study.

• At the end of the third day, the interviewer would call you to ask some questions about your experience using the phone application.

As I mentioned, use of the phone app would take place on three consecutive days, with interviews on the first and third days. Those who participate will receive a check for $40 in appreciation for their time, after they send the phone back to us.

If you are interested and available for this, I would like to ask you a few questions to see if you are eligible to participate.

IF NEEDED: Westat, a research company in Rockville, Maryland is conducting survey research for the U.S. National Cancer Institute (NCI) to test a mobile phone app. We'll be getting feedback about how the app might be changed to make it easy to use to record daily activities.

Ql. As I said, the first interview will take place at Westat's headquarters, located on Research Boulevard in

Rockville, Maryland. Are you within driving or commuting distance to this location?

PROVIDE MORE INFO ON LOCATION IF NEEDED

□ Yes

□ No- TERMINATE AND THANK ("Based on the study design, our first interviews are going to be conducted at this location, so it looks like we can't include you at this time.")

Q2. Do you have access to a WiFi network - either at home or at a WiFi hotspot?

□ Yes

□ No- TERMINATE AND THANK ("Based on the study requirements, it looks like we can't include you at this time.")

Q3. The interview on the third day will take place by telephone [IF WEBEX]: online meeting software called WebEx. Do you have access to a telephone? [IF WEBEX]: and a computer at the same time?

□ Yes

□ No - TERMINATE AND THANK ("Based on the study design, our follow-up interviews are going to be conducted by telephone [AND IF WEBEX] [by computer] so it looks like we can't include you at this time.")

Q4. We are looking for people who have and use a cell phone. Do you currently have a cell phone?

□ Yes

□ No -- TERMINATE AND THANK ("Based on the study design, it looks like we can't include you at this time.")

Q5. Which type of operating system does your cell phone have? [IF NEEDED: Android is one type of operating system- the system that controls a smartphone. Android phones are different from iPhones. The brand of the phone is not the same as the operating system.]

□ Android

□ iPhone [ TERMINATE AND THANK ("Based on the study design, we need people who use an Android smart phone so it looks like we can't include you at this time.")

□ Don't know [TERMINATE AND THANK ("Based on the study design, we need people who use an

Android smart phone so it looks like we can't include you at this time.")

INTERVIEWER: RECRUIT THOSE WHO HAVE AN ANDROID PHONE

Q6. How comfortable are you with using apps on your phone? Would you say...

□ ^{Not at all comfortable}

□ ^{A little comfortable}

□ Moderately comfortable, or

□ Very comfortable?

□ Not sure

INTERVIEWER: WE WILL RECRUIT A RANGE ON THIS, BUT IT IS LESS IMPORTANT TO HAVE VARIATION ON THE MAIN DEMOGRAPHIC VARIABLES.

Q7. [ASK ONLY IF NOT OBVIOUS FROM VOICE]: What is your gender?

□ Male

□ Female

INTERVIEWER: RECRUIT A MIX OF MALES AND FEMALES.

Q8. Have you participated in a focus group or individual interview in the past three months?

□ No

□ Yes- COLLECT DEMOGRAPHIC INFORMATION, THANK, AND PLACE ON WAITING LIST ("For this study, we are looking for participants who have not taken part in a focus group or interview in the past three months, so it looks like we can't include you at this time. If“you would like, we can collect the rest of

your information and place you on a waiting list.")

Q9. Which of the following age categories are you in?

□ 18-29

□ 30-44

□ 45-54

□ 55-64

□ 65 and older -TERMINATE AND THANK ("Based on the study design, we need people who are under between the ages of 18 and 65 so it looks like we can't include you at this time.")

INTERVIEWER: RECRUIT A MIX OF AGES, if possible.

QlO. Are you Hispanic or Latino?

□ Yes

□ No

Qll. What is your race? MARK ALL THAT APPLY.

□ White

□ Black or African American

□ Asian

□ American Indian or Alaska Native

□ Native Hawaiian or Other Pacific Islander

INTERVIEWER: RECRUIT A MIX OF RACES.

Q12. What is the highest level of education you have completed?

□ 11^th grade or less

□ 12 years of school, no diploma

□ GED or high school graduate (diploma)

□ Some college or technical school

□ College or technical school graduate

□ Post-graduate

INTERVIEWER: TRY TO RECRUIT A MIX OF RESPONDENTS FROM EACH EDUCATION GROUP.

Q13. What is your current employment status? Are you...

□ Employed for wages

□ Self-employed

□ Currently out of work

□ A homemaker

□ A student

□ Retired

INTERVIEWER: RECRUIT A MIX OF EMPLOYMENT STATUS.

Closing

You are eligible to help with this research project. Please note we will not share your personal information with anyone not involved in this study. Are you interested in participating?

YES -Thank you so much for your willingness to help us. If you are selected as a participant you will receive a check for $40 after completing the in-person session here at Westat, the interview on the third day, and sending the phone back to us. If you are chosen as a participant, I will call you back within a few days to set up a time for you to meet with someone from the study team.

NO -Thank you for taking the time to talk with me today and have a great (day/evening).

Rev Mar 2013