Form 1 Screener

OMB Number: 0925-0643

Expiration Date: 10/31/2014

Back To Sleep Focus Groups: Screener for Private Sector Health Professionals (Daycare Providers)

We are conducting focus groups with private sector health professional that provide care to infants to talk about some health issues. We are not selling or promoting any product or service. For your participation in this study you will receive $40. The focus groups will last about 2 hours. 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 15 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 private sector health professionals 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. Do regularly work with children between birth and 1 year old?

( ) Yes Continue

( ) No Thank and Terminate

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. What is your profession?

( ) Daycare worker Continue

( ) Other Thank and Terminate

5. Do you work in a daycare center or in-home daycare?

( ) Daycare center Continue

( ) In-home daycare Continue

( ) Other Thank and Terminate

6. [For in-home daycare workers] How many infants under the age of 1 do you care for?

( ) 2 or more Continue

( ) 1 Thank and Terminate

7. [For daycare center workers] Do you manage or oversee other childcare workers?

( ) Yes Continue

( ) No Continue

Recruit 1 manager for every three daycare center non-managers.

1. How many years of experience do you have as a daycare provider?

( ) Less than 10 years Continue

( ) 10 or more years Continue

Recruit 6 with less than 10 years of experience and 6 with more than 10 years of experience.

8. During the focus group, you will be asked to read and review materials in English. 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 SIDS.

For your participation in this study you will receive $40.

9. 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________________________

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 15 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 (0925-0643). Do not return the completed form to this address.