Att 6 - Example of Screener

Form Approved

OMB No. 0920-0792

Exp. Date xxxxxxxx

Attachment 6- Example of EHS-Net Data Collection Instrument- Recruiting Screener

EHS-Net Cooling Practices Study

Hello this is __________ with the _________ Health Department. We are working with the Centers for Disease Control and Prevention (CDC) on a research project that focuses on cooling policies and practices and your location has been randomly selected to participate.

Does this establishment cool any potentially hazardous foods from 135^oF or above to a 41^oF or below? Potentially hazardous foods would include any food of animal origin such as meat, poultry, seafood or dairy as well as cooked vegetables.

􀂅 No → Thank you for your time. (end interview)

􀂅 Yes ↓ (Go to next paragraph)

Great! The study consists of an interview with the manager and observation of cooling practices. Specifically we would like to observe how potentially hazardous foods are cooled to refrigerated temperatures. Please keep in mind this is not an inspection and participation is voluntary but we would really appreciate your participation. Also, if you decide to participate, y

our name and your restaurant’s name will not be recorded on the data collection form, nor will they be included in any reports.

Having said that, I need to let you know that at any time during the survey if I see something that is an imminent health hazard, such as no power, no water or sewage on the floor, I will need to stop the study and report the problem to your local health department.

Could we schedule a time to come out when you will be cooling potentially hazardous food and complete the survey?

􀂅 No → Thank you for your time.

􀂅 Yes ↓ (Go to next paragraph)

Great! I’ll visit your restaurant for about an hour and a half. Keeping in mind that a manager responsible for managing the kitchen must be available for the interview, and that we would like to be there when cooling is taking place, when would be a convenient time to schedule the visit?

Date: Time:

Please call me at if you need to cancel or re-schedule, or if you have any questions.

Public reporting burden for this collection of information is estimated to average 3 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 Information Collection Review Office, MS D-74; 1600 Clifton Road NE, Atlanta, Ga. 30333; ATTN: PRA (0920-0792)