1 Screener

OMB Number: 0925-0643

Expiration Date: 10/31/2014

Non-Medically Indicated Induction Prior to 39 Weeks of Gestation

Focus Groups:

Recruitment Screener for Pregnant Women and Expecting Fathers

We are conducting focus group discussion sessions with currently pregnant women and currently expecting fathers 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 1½ hours (90 minutes). The discussions 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.

[For recruiters: 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 pregnant women and expecting fathers 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 Ellen Robinson at 240-221-4273.”]

1. 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

2. 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

3. Are you currently pregnant or are you currently an expecting father?

( ) Currently pregnant Continue

( ) Currently an expecting father Continue

( ) No Thank and Terminate

4. Do you have other children?

( ) Will be a first-time parent when baby is born Continue

( ) Have other children Continue

5. 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.

7. 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

Refer to the table for recruitment.

8. Which of the following categories best describes your total annual household income?

( ) $40,000 or lower Continue

( ) Between $40,000 and $50,000 Thank and Terminate

( ) $50,000 or higher Continue

Refer to the table for recruitment.

INVITATION

Thank you for answering our questions. We would like to invite you to participate in a 1½ -hour group discussion to hear your thoughts on pre-term birth.

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

9. Are you interested and able to participate?

( ) Yes Schedule focus group

( ) No Thank and terminate

Your discussion will be held at: LOCATION [FOR IN-PERSON GROUPS] on: DATE & TIME (provide directions/parking instructions or call-in information, accordingly).

If you use glasses for reading, please bring them.

It is very important that you arrive on time. If, for any reason, you have to cancel, please call us at ___-___-____ so we can find someone to replace you.

May I verify your name, address, phone number(s), and email for a confirmation/reminder call the day before your focus group discussion session?

Name __________________________________________________________________

Address __________________________________________ Zip Code ___________

Home Phone ____________ Work Phone ______________ Cell Phone ______________

Email ___________________________________________________________________

[FOR IN-PERSON GROUPS:] Please arrive at least 15 minutes before your start time

so that you can sign a Consent Form!

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

Recruit for the following 5 focus groups:

(1) Telephone focus group: 12 first-time currently pregnant women (from a variety of geographic locations)

(2) Telephone focus group: 12 currently pregnant women who also have other children (from a variety of geographic locations)

(3) In-person focus group: a mix of 12 both first-time currently pregnant women and currently pregnant women who also have other children (in the Washington, DC area)

(4) In-person focus group: a mix of 12 both first-time currently pregnant women and currently pregnant women who also have other children (in the Chicago, IL area)

(5) Telephone focus group: 12 male spouses/partners of women listed above (from a variety of geographic locations)

Table for Recruitment

Target Audience:	Geographic locations across the United States	Washington, DC	Chicago, IL
Currently pregnant women: First-time mothers	Telephone Focus Group #1: 9 female participants --Half Caucasian --Half minority --High income* --High education*
Currently pregnant women: Mothers with other children	Telephone Focus Group #2: 9 female participants --Half Caucasian --Half minority --High income --High education
Currently pregnant women: Both first-time mothers and mothers with other children		In-person Focus Group #3: 9 female participants --Half Caucasian --Half minority --Low income** --Low education**	In-person Focus Group #4: 9 female participants --Half Caucasian --Half minority --Low income --Low education
Fathers/male guardians: Male spouses/partners of women listed above	Telephone Focus Group #5: 9 male participants --Mix race and ethnicity --Mix income and education

*For the purposes of this project, “high income” will be defined as living in a household earning an annual total household income of $50,000 or more and a “high level of education” as having at least some college.

**For the purposes of this project, “low income” will be defined as living in a household earning an annual total household income of $40,000 or less and a “low level of education” as high school education or less and/or vocational/technical school.

^ 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.