Form 1 Recruitment Screener for Breastfeeding Women

OMB Number: 0925-0643

Expiration Date: 10/31/2014

Eunice Kennedy Shriver National Institute of Child Health and Human Development

Safe to Sleep Telephone Focus Groups

Participant Recruitment Screener

--Focus Group with Breastfeeding Women--

We are conducting a telephone focus group with breastfeeding women to talk about infant health issues. We are not selling or promoting any product or service. Everyone who participates in the focus group will receive an incentive of $20. The focus group will last 60 minutes. The discussion will be audio-recorded and confidential to the extent allowed by law. First names only will be used during the discussion. In the final summary report, your individual name will never be connected to a comment you make during the discussion. To see if you qualify to participate in the focus group discussion, we need to ask you a few questions. These questions will take less than five minutes.

RECRUIT 11 TOTAL PARTICIPANTS FOR 1 FOCUS GROUP (7-9 PARTICIPANTS WILL BE VIRTUALLY SEATED; ALL PARTICIPANTS WHO SHOW, EVEN THOSE WHO ARE EXCUSED, WILL RECEIVE THE INCENTIVE).

Confirm that the individual speaks English clearly. _____

1. Are you currently breastfeeding?

( ) Yes

( ) No THANK AND TERMINATE

2. Do you have any other children?

( ) Yes PROCEED TO QUESTION 2a

( ) No PROCEED TO QUESTION 3

2a. Did you breastfeed your last child?

( ) Yes

• If yes, did you exclusively breastfeed or did you combine formula with breastfeeding for your last child? ____[ENTER RESPONSE]____________

• For how long did you breastfeed your last child? _____ months or _____ weeks

( ) No

3. For how long do you plan on breastfeeding this baby? _____ months or _____ weeks

RECRUIT A MIX OF FIRST-TIME MOTHERS WHO ARE BREASTFEEDING AND MOTHERS WHO HAVE BREASTFED BEFORE.

4. What is your age? _____ years

5. What is your city and state? ________________

RECRUIT A MIX OF GEOGRAPHIC LOCATIONS.

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

(     ) Not Hispanic or Latino

(     ) Hispanic or Latino

(     ) Intentionally withheld

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

(     ) White............................................................................................................ Continue

(     ) Black or African American.......................................................................... Continue

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

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

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

(    ) Intentionally withheld                                                                                    Continue

INCLUDE ABOUT 2-3 WHITE/CAUCASIAN, 2 AFRICAN AMERICAN/BLACK, 1-2 AMERICAN INDIAN/ALASKA NATIVE PARTICIPANTS IN THE FOCUS GROUP.

8. What is the highest level of education that you have completed?

_____ Less than high school

_____ Completed high school

_____ Some college/university

_____ Some technical school

_____ Completed college/university/technical school

_____ Any degree after college

INCLUDE A MIX OF EDUCATION LEVELS.

[Use the following language when terminating a call:
“Thank you very much for your time today. We are looking to recruit a wide variety of breastfeeding women from across the United States to help with this study. Unfortunately, we have filled participant slots with your specific characteristics. Again, thank you for your interest.”]

INVITATION

Thank you for answering our questions. We would like to invite you to participate in a 1-hour telephone focus group discussion with other breastfeeding women to hear your thoughts on breastfeeding and safe infant sleep. If you agree to participate you will receive an incentive of $20 as a token of appreciation for your time.

1. Are you willing to participate?

( ) Yes SCHEDULE

( ) No THANK AND TERMINATE

FOR SCHEDULED PARTICIPANTS:

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

Name_________________________________________________________________

Address_______________________________________________________________

City/State/Zip___________________________________________________________

Day Number_______________________ Night Number_________________________

Email address­­­­­­­­­­­­­­­___________________________________________________________

What is the best telephone number to reach you? ________________________

We will contact you again, the day before the telephone focus group discussion, as a reminder.

^ Public reporting burden for this collection of information is estimated to average 5 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.