Formative - Developmental

ATTACHMENT B.5.5 EXEMPLAR INTERVIEW SCREENING SCRIPT OMB #: 0925-0593

LOI2-QUEX-13 EXPIRATION DATE: 07/31/2013

HEALTH DISPARITIES INTERVIEW (Phase 2)

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 INELIGIBLE, but eligible for M0-5 

You are not eligible for this portion of the study, however, if you would like I can keep your information and we can contact you about future portions of the study.

If ELIGIBLE 

You are eligible for the study, do you wish to participate? Joining the study would entail one interview now and one interview six months from now, after you’ve had your baby. Each interview will take around an hour and a half to complete and you will be compensated $25 for each.

There are minimal risks to you if you choose to participate. Your 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?

1. Would you like to participate? [ ] NO  Thank you for your time and cooperation.

[ ]YES  proceed to questions 2

2. What would be a good time and day for you, interviews will take place AT YOUR HOME/AT SITE _________________ .

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.

ID CODE

___________________

First Time Mother Interview Screener (T1/T2)

1. What is your month and year of birth?

|___|___| |___|___|___|___| (ineligible if < 18)

MM YYYY

2. Do you have any children? [ ] NO  proceed to question 3

[ ] YES  ineligible for T1 ask follow up below to see if eligible for M0-5

If yes, how many? _____ what are their ages? _______

if between 6months and 5, could be eligible for M0-5, offer to save information

3. Are you currently pregnant? [ ] YES  proceed to question 4

[ ] NO (ineligible, end screening)

4. How many weeks pregnant are you? _____ (must be at least 20 weeks at Time 1 interview)

If not 20 weeks currently, give option to save information and call back when eligible.

5. Do you consider yourself to be Hispanic, or Latina? [ ]NO  proceed question 6

[ ] YES  ask follow up below, then proceed to question 6

see site specific recruitment goals to determine if eligible based on Hispanic ethnicity

1. 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_______________________________________ [ ]

6. 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

7. How well would you say you speak English?

Not at all A little Pretty Well Extremely Well

Low English Proficiency English Proficiency

site specific ineligibility

8. At Spanish available sites:

Which language would you prefer to be interviewed in? [ ] ENGLISH

[ ] SPANISH

9. What is the highest degree or level of school that you have completed?

ELEMENTARY

 NURSERY SCHOOL TO 4^TH GRADE

 5^TH-6^TH GRADE

 7^TH-8^TH GRADE

HIGH SCHOOL

 9^TH GRADE

 10^TH GRADE

 11^TH GRADE

 12^TH GRADE (NO DIPLOMA)

Low education (HS or Less)

 HIGH SCHOOL DIPLOMA

 GED OR EQUIVALENT

High Education (Above HS/GED)

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.)

Public reporting burden for 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593). Do not return the completed form to this address.