Example - Back To Sleep_Attachment A_Screener for Caregivers_Revised 8-30-11

O MB Number: 0925-XXXX (New)

Expiration Date: xx/xxxx

Back To Sleep Focus Groups: Screener for Caregivers

We are conducting focus groups with parents and caregivers of infants to talk about some health issues. We are not selling or promoting any product or service. Everyone who participates in the focus group will be paid $50. The focus groups will last about 1 hour. The discussion will be observed and recorded; however, no one will know your name or contact information.

To see if you qualify to participate in the focus group we need to ask you a few questions. These questions will take less than five minutes to answer.

Please use the following language for termination of screening:

“Thank you very much for your time today. We are looking to recruit a wide variety of parents and caregivers from across the country to help with this study, and we have already completed enough surveys from people with similar backgrounds. Again, thank you for your interest. If you have any questions about the research, please contact Elyse Levine at 202-884-8913.”

1. Are you a mother, father, grandparent or main caregiver of a son or daughter who is between birth and 1 year of age?

( ) Mother Continue

( ) Father Continue

( ) Grandparent Continue

( ) No Thank and Terminate

Recruit 5 mothers, 2 fathers, and 2 grandparents/caregivers of either gender for each group.

2. In the past 6 months have you participated in a market research study, focus group or interview, not including online surveys, where you were paid for your time and/or for providing your opinions?

( ) Yes Thank and Terminate

( ) No Continue

3. Have you or anyone in your home studied, worked in or retired from any of the following industries?

(Read and record response)

( ) Marketing or public relations Thank and Terminate

( ) Advertising Thank and Terminate

( ) Market research Thank and Terminate

( ) Medical/health field (e.g., doctor, nurse, dentist, paramedic) Thank and Terminate

( ) Pharmaceutical industry Thank and Terminate

( ) None of the above Continue

4. Which of the following categories best describes your ethnic background?      

(     ) Hispanic or Latino

(     ) Non-Hispanic or Non-Latino

(     ) Intentionally withheld

1. Which of the following racial categories best describes your racial background?

(     ) African American/Black............................................................................... Continue

(     ) Caucasian/White.......................................................................................... Continue

 (    ) Asian............................................................................................................ Continue

(     ) American Indian or Alaska Native............................................................... Continue

(     ) Native Hawaiian or other Pacific Islander …………………………………Continue

(    ) Intentionally withheld                                                                                    Continue

Refer to the table for recruitment.

6. [If Hispanic][Do not read: Were the screener questions conducted in English or Spanish?]

( ) English Score 1

( ) Spanish Score 0

7. Do you speak mostly Spanish or English at home?

( ) Mostly Spanish Score 0

( ) Both about the same Score 1

( ) Mostly English Score 2

8. How would you describe your identification as Hispanic/Latino (a)?

( ) Not at all strong Score 0

( ) Not very strong Score 1

( ) Moderately strong Score 2

( ) Strong Score 1

( ) Very strong Score 2

Please calculate the score from questions 5 through 7, minus 1, and record total.

Thank and terminate Hispanics with a score over 3.

9. Which of the following categories best describes your level of education?

( ) Did not graduate high school Continue

( ) Completed high school Continue

( ) Some college/technical training/associate’s degree Continue

( ) Completed college Continue

( ) Graduate degree (master’s or higher) Continue

Recruit a mix.

10. During the focus group, you will be asked to read and review materials in [English or Spanish]. Are you comfortable doing this activity?

( ) Yes Continue to Invitation

( ) No/Don’t know Thank and Terminate

INVITATION

Thank you for answering our questions. We would like to invite you to participate in a group discussion to hear your thoughts on Sudden Infant Death Syndrome (SIDS).

If you agree to participate you will receive $50 as a token of appreciation for your time.

11. Are you willing to participate?

( ) Yes Schedule interview time

( ) No Thank and terminate

FOR SCHEDULED INTERVIEWS

We will send you a confirmation letter, consent form, and information about the group discussion. What is your mailing address so we can send you the materials?

Name_________________________________________________________________

Address_______________________________________________________________

City/State/Zip___________________________________________________________

Day Number_______________________ Night Number_________________________

Email address­­­­­­­­­­­­­­­___________________________________________________________

What is the best number to reach you? ________________________

Thank you for your time. We will contact you again to remind you of your interview date and time.

^ Public reporting burden for this collection of information is estimated to average 10 minutes, 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 (0925-0590). Do not return the completed form to this address.