HEALTH DISPARITIES COGNITIVE INTERVIEW (Phase 1)
TELEPHONE SCREENING SCRIPT
Hello, my name is ______________ from the department of Pediatrics at Johns Hopkins.
We are working on a research study about different things and can affect a mother and her children’s health. May I ask you some questions to see if you are eligible to participate?
NO:
Thank you for your time
YES:
We will be collecting information about you during this phone call. Your taking part in this phone call is completely voluntary.
Your information will only be seen by researchers at Johns Hopkins. We will make sure that the information we collect from you is kept private and used only for the research study we are discussing. If you do not agree to continue the phone call, it will not affect your care at Johns Hopkins.
If you are not eligible or do not wish to participate you will have the option to let us keep your information on file so we can contact you about future opportunities. If you do not want us to keep this information we will destroy all documents with your name on them.
ADMINISTER SCREENING SHEET (separate document):
We will be asking some basic questions about your age, race/ethnicity, and income level.
IF NOT ELIGIBLE:
Unfortunately you are not eligible for this study, would like you me to keep you information on file and contact you at a later point?
YES:
Take down contact information
NO:
Thank you for your time.
IF ELIGIBLE:
You are eligible to participate in this study. If you wish to participate you will be asked to come in and complete a onetime interview with one of our researchers. During the interview we would ask you about your thoughts on some survey questions we are hoping to include in a larger national study. We are doing these interviews because we want to know if the survey questions are easy to understand and meaningful across different groups of people. The interview would take approximately an hour and a half to complete.
There are minimal risks to you if you choose to participate. You participation is completely voluntary and you will have the right to refuse any of our questions.
There is no cost to you to participate in the study and we will give you $25 in cash or gift card to thank you for your time.
Do you have any questions?
Do you think you would like to take part in this research?
YES:
Let’s make an appointment for your interview. You will meet with _____________ at __:__ AM/PM on _____________________. If you need to cancel or reschedule call ____________ at _________________.
NO:
Would like you me to keep you information on file and contact you at a later point?
YES:
Take down contact information
NO:
Thank you for your time.
Cognitive Interview Screener
ID CODE
___ ___ ___ __
Date of Birth
|___|___| |___|___| |___|___|___|___| (ineligible if < 18)
MM DD YYYY
Mother with child or children ages 0-5 [ ] YES [ ] NO (ineligible if no)
(see site specific recruitment goals to determine if eligible based on Hispanic ethnicity)
If yes, do you identify with any of the following Spanish, Hispanic, or Latino groups?
PUERTO RICAN [ ]
CUBAN/CUBAN AMERICAN [ ]
DOMINICAN (REPUBLIC) [ ]
MEXICAN [ ]
MEXICAN AMERICAN [ ]
CENTRAL OR SOUTH AMERICAN [ ]
INTERVIEWER NOTE: Do not read category OTHER to participant. If participant indicates OTHER, please fill in below:
OTHER: SPECIFY_______________________________________ [ ]
2. What race do you consider yourself to be? You may select one or more.
WHITE………………………………………………………………………………… [ ]
BLACK OR AFRICAN AMERICAN…………………………………………. [ ]
NATIVE AMERICAN OR ALASKA NATIVE……………………………. [ ]
ASIAN………………………………………………………………………………… [ ]
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER……………… [ ]
INTERVIEWER NOTE: Do not read category OTHER to participant. If participant indicates OTHER, please fill in below:
OTHER: SPECIFY__________________________________ [ ]
(site specific ineligibility)
3. (SKIP IF HISPANIC)
In addition [or if you selected OTHER] to the categories of ethnic or racial origin I have just shown you, are there any other ethnic or racial categories you identify with that are not included in these lists? You may use more than one category, for example Chinese Vietnamese, Cuban African American, Korean, Haitian, or Somali.
ANSWER: ___________________________________________________
4. How well would you say you speak English?
Not at all A little Pretty Well Extremely Well
Low English Proficiency English Proficiency
5. Were you born in the United States? [ ] YES [ ]NO
6. Were your parents born in the United States?
MOTHER [ ] YES [ ] NO
FATHER [ ] YES [ ]NO
8.What is the highest degree or level of school that you have completed?
ELEMENTARY
NURSERY SCHOOL TO 4TH GRADE
5TH-6TH GRADE
7TH-8TH GRADE
HIGH SCHOOL
9TH GRADE
10TH GRADE
11TH GRADE
12TH GRADE (NO DIPLOMA)
HIGH SCHOOL DIPLOMA
GED OR EQUIVALENT
COLLEGE
SOME COLLEGE CREDITS, BUT LESS THAN 1 YEAR
1 OR MORE YEARS OF COLLEGE, BUT NO DEGREE
ASSOCIATE DEGREE: OCCUPATIONAL, TECHNICAL, OR VOCATIONAL PROGRAM
ASSOCIATE DEGREE: ACADEMIC PROGRAM
BACHELOR’S DEGREE (e.g., BA, BS)
GRADUATE
MASTER’S DEGREE (e.g., MA, MS, MSW, MEng, MBA)
PROFESSIONAL SCHOOL DEGREE (e.g., MD, DDS, DVM, JD)
DOCTORAL DEGREE (e.g., Ph.D., Ed.D.)
Page
| File Type | application/msword |
| File Title | Sample Telephone Script |
| Author | Washington University MS |
| Last Modified By | Nolen Morton |
| File Modified | 2011-09-07 |
| File Created | 2011-09-07 |