Form Approved
OMB No. 0920-0910
Expiration Date 1/31/2015
Hello, my name is and I’m from [FACILITY NAME], a local market research firm. We are working with RTI International, a non-profit research organization, and the Centers for Disease Control and Prevention (or CDC) on a research study about tobacco products and would like to include your opinions. I want to assure you that we are not from a tobacco company or a company that sells quit-smoking aids. I am not selling or promoting any product. I am calling to invite you to take part in a research study about tobacco products.
We are holding a group discussion on [DATE] with 7 other women like you. The discussion group starts at [TIME] and will last about 90 minutes. For study purposes, the group discussion will be audio and video recorded, and project team members may observe the discussion. If you qualify for this project and participate in our focus group, you will receive $75.00 to show appreciation for your time. Your opinions will help to contribute to current efforts to develop materials about the use of tobacco among women of childbearing age.
First, however, I need to ask you a few questions to see if you qualify for the study.
Which of the following categories best describes your age? (Read list. Recruit a mix to show per group.)
18–23 [NOT ELIGIBLE - THANK & END]
23–29
30–35
36–40 [NOT ELIGIBLE - THANK & END]
Public reporting burden of this collection of information is estimated to average 5 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; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0910)
Are you currently pregnant?
Yes (Have been to prenatal visit and/or have taken pregnancy test) [GO TO Q4]
Eligible as pregnant participant
No
Are you planning or trying to become pregnant in the next year?
Yes
No [NOT ELIGIBLE - THANK & END]
Have you smoked at least 100 cigarettes, cigars, little cigars, or cigarillos in your lifetime? (If respondent hesitates, inform them that there are 20 cigarettes in each cigarette pack and that 5 packs would equal 100 cigarettes. If respondent asks, inform them to count all these types of tobacco together. For example, if they smoked 50 cigars and 70 cigarettes, they would be a “YES.”)
Yes
No
Have you ever used other tobacco products, like snus, e-cigarettes, chewing tobacco, or other smokeless tobacco products?
YES
NO
Do you currently smoke cigarettes, cigarillos, or little cigars…? (Read list. Recruit a mix to show per group.)
Every day [GO TO Q8]
Some days [GO TO Q7]
Not at all (FORMER SMOKER) [GO TO Q9]
7. [SMOKERS/SOME DAYS] In an average week, how many days do you smoke? Would you say…? (Read list. Recruit a good mix to show per group.)
Less than once a week [THANK AND TERMINATE]
1 day a week [GO TO Q8]
2 days a week [GO TO Q8]
3-4 days a week [GO TO Q8]
5-6 days a week [GO TO Q8]
7 days a week [GO TO Q8]
On the days you do smoke, on average, how many cigarettes, cigars, little cigars, or cigarillos do you smoke?
__________ [ENTER WHOLE NUMBER]
[FORMER SMOKER] When did you stop smoking?
Before you became pregnant [NOT ELIGIBLE - THANK & END]
After you became pregnant
How long has it been since you last smoked a cigarette, cigar, little cigar, or cigarillo?
In the last 30 days [NOT ELIGIBLE - THANK & END]
More than 30 days ago
In the past 5 years, have you or any member of your household worked for any of the following? [IF YES TO ANY, NOT ELIGIBLE - THANK & END.]
A tobacco or cigarette company,
A public health or community organization involved in communicating the dangers of smoking or the benefits of quitting,
A manufacturer of smoking cessation aids,
A marketing, advertising or public relations agency or department,
The Federal Government (If yes, read list. ELIGIBLE IF NONE OF THE FOLLOWING:)
Food and Drug Administration,
The National Institutes of Health,
Centers for Disease Control and Prevention,
The Substance Abuse and Mental Health Services Administration, and
The Centers for Medicare & Medicaid Services.
Have you ever lobbied on behalf of the tobacco industry or personally represented or worked on behalf of a tobacco company in connection with a tobacco lawsuit?
Yes [NOT ELIGIBLE - THANK & END]
No
Have you participated in any paid market research such as a focus group in the past 6 months?
Yes [NOT ELIGIBLE - THANK & END]
No
What is the highest level of education that you have completed? (Read list.)
Less than high school
High school graduate or GED
Some college or 2-year degree
College degree
Post graduate degree
Are you Hispanic or Latina?
Yes
No
What describes your racial/ethnic background? (Read list. Respondent may select more than one.)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Do you have any biological children under the age of 18 in your household?
Yes
No [GO TO Q19]
18. How old is the youngest child/children? ___________(months, years)
[IF CURRENT SMOKER] Which of the following statements best describes the rules about smoking inside your home now? (Read list.)
No one is allowed to smoke anywhere inside my home
Smoking is allowed in some rooms or at some times
Smoking is permitted anywhere inside my home
[IF HISPANIC] Is Spanish your first language?
Yes
No
We will have group discussions in both English and Spanish. Would you prefer to participate in an English-speaking group or Spanish-speaking group?
English-speaking
Spanish-speaking
Thank you for answering all of my questions. Unfortunately, you are not eligible to participate in this study. There are many possible reasons why people may not be eligible. These reasons were decided earlier by the project team. We value your interest in the focus groups. Thank you for being willing to help us.
Thank you for answering all of my questions. We are looking for women who have a variety of background characteristics. At this time, we need to include women with different background characteristics than yours. However, we would like to keep your name contact information and if a slot opens up we will call you. Would that be OK? We value your interest in the focus groups. Thank you for being willing to help us.
Person said YES > Record answer and keep contact info
Person said NO > Record answer and delete contact info
Thanks for answering all of my questions. We would like to invite you to take part in a group discussion with other women to talk about tobacco products. The focus group will take place on [DATE] at [TIME] and will last about 90 minutes. For appreciation of your time and opinions, you will receive $75 cash.
Also, we need to let you know that there will not be any childcare provided at the facility, so please make the appropriate childcare arrangements.
Would you like to participate in the group discussion at [TIME] on [DATE]?
Yes [GO TO CONFIRMATION]
No (Refuse to participate) [THANK & END]
Confirmation Script
I would like to send you a confirmation letter and directions to the facility. May I please have your mailing (or email) address? May I also have your telephone number, so we can give you a reminder call? [Verify address and phone number.] Name: ____________________________ Address: ____________________________________________________ City: __________________________________ State: ___ Zip: ________ Phone: ________________________ Email: _________________________ Date of Focus Group: ____________ Time: ___________ We are only inviting a few people, so it is very important that you notify us as soon as possible if you are unable to attend. You can call [NAME] at [CONTACT INFO] if you need to cancel. We look forward to seeing you on [DATE] at [TIME]. Please try to arrive at least 15 minutes prior to the group. Thank you so much for your time today |
Read if necessary:
If you have questions about the study, please call the RTI project director, Dr. Julia Kish Doto, at 1‑800‑334‑8571, x28280. If you have concerns about how participants are being treated in the study, you may contact RTI’s Office of Research Protection toll-free at 1-866-214-2043.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Eguino-Medina, Paula |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |