0920-0572 Testing of brand Appendix A1-Screener-Consumers 010

Appendix A: Screening Instruments Form Approved
OMB No. 0920-0572
Expiration Date: 2/28/2015

Testing of Brand Concepts, Messages and Materials for CDC’s National Diabetes Prevention Program

Discussion Group Recruitment Screener: General Public – March—April 2013

• Recruitment: Recruit 10 general public members for 8 participants to show for each focus group (total = 30 participants per market; 120 overall)

• Incentive: $50 per participant

• Duration: 1.5 hours or less per consumer focus group

Introduction

Hello, my name is ________ and I am calling from __________________, a marketing research firm in the ________________ area. I know you receive a lot of telephone calls from telemarketers, but I assure you, this is not a sales call. I am calling today to see if you might qualify to participate in a discussion group. Everyone who is eligible and participates will receive a gift of $50. The research study is sponsored by the Centers for Disease Control and Prevention, also known as the CDC. We are interested in hearing the opinions of people in our community on several topics.

May I please ask you a few questions? Thank you.

Screens

1b. Do you, or does any member of your household or immediate family work for:

( ) A market research company Terminate

( ) An advertising agency or public relations firm Terminate

( ) The media (TV/radio/newspapers/magazines) Terminate

( ) As a healthcare professional

(doctor, nurse, pharmacist, dietician, etc.)…………………………..…... Continue if not self

Public Reporting Burden Statement

Public reporting burden of this collection of information is estimated to average 10 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0572).

2b. Have you participated in a focus group, intercept interview, telephone survey, and/or online survey in which you were asked your opinions regarding a product, a service, or advertising within the past six months?

( ) Yes …………………………………….. …Terminate

( ) No Continue to 44a

44a(1). Do you have [prediabetes]?

( ) Yes …………………………………….. …Continue [Skip to Q6a]

( ) No Continue to 16f

16f. Are you planning to be physical active, or exercise, at least 3 times a week in the next 30 days?

( ) Yes Continue

( ) No Continue

How tall are you? __________ feet _______________ inches

[Ask the person if he or she weighs more than the weight in pounds that is given directly to the right of the height.]

Do you weigh more than __________ pounds?”

( ) Yes …………………………………….. …Continue

( ) No …………………………………….. …Continue

At-Risk Weight Chart

Height	Weight in Pounds
4’10”	129
4’11”	133
5’0”	138
5’1”	143
5’2”	147
5’3”	152
5’4”	157
5’5”	162
5’6”	167
5’7”	172
5’8”	177
5’9”	182
5’10”	188
5’11”	193
6’0”	199
6’1”	204
6’2”	210
6’3”	216
6’4”	221

44a(2). Do you have:

[…a parent, sister, or brother with diabetes?]

( ) Yes Continue

( ) No Continue

[…(females only) a personal health history of gestational diabetes, or diabetes while pregnant?]

( ) Yes Continue

( ) No Continue

[…(females only) a personal health history of giving birth to a baby weighing 9 or more pounds?]

( ) Yes Continue to Q6a

( ) No Continue to Q6a

6a. Please indicate your race or ethnic background. Are you?

Ethnicity:

( ) 1. Hispanic or Latino Continue

( ) 2. Not Hispanic or Latino Continue

SELECT ONE OR MORE.

Race:

( ) 1. White Continue

( ) 2. Black or African-American Continue

( ) 3. American Indian or Alaska Native Continue

( ) 4. Native Hawaiian or Other Pacific Islander Continue

( ) 5. Asian Continue

[Continue only if 44a(1)=Yes, OR 16f=No, OR At-Risk Weight=Yes, OR any 44a(2)=Yes, OR 6a Ethnicity=Hispanic or Latino, OR 6a Race=Black or African American, Native Hawaiian or Other Pacific Islander, or American Indian or Alaska Native]

[Attempt to recruit even mix by race/ethnicity (Hispanics, AA, Caucasians/Others across groups]

4a. What is the highest level of education you have completed?

( ) Grade school Terminate

( ) Less than high school graduate/some high school Terminate

( ) High school graduate or completed GED Continue

( ) Some college or technical school Continue

( ) Received four-year college degree Continue

( ) Some post graduate studies Continue

( ) Received advanced degree Terminate

( ) Other: _____________________ …………………………………………….. Terminate

[Focus Groups: Recruit a mix in each segment]

25a. What is your age? _______________ (record age) [Terminate if not age 40 to 65]

[Recruit a mix in each segment]

13a. Which of the following categories best describe your total, annual household income?

( ) Under $20,000/year Terminate

( ) $20,001 - $30,000/year Continue

( ) $30,001 - $40,000/year Continue

( ) $40,001 - $50,000/year Continue

( ) $50,001 - $60,000/year Continue

( ) $60,001 - $80,000/year Continue

( ) $80,001 - $100,000/year Terminate

( ) Over $100,000/year Terminate

[Recruit a mix in each segment]

10a. What is your current occupational status? Would you say…?

( ) Employed full time Continue

( ) Employed part time Continue

( ) Unemployed Continue

( ) Homemaker Continue

( ) Student Continue

( ) Retired, or Continue

( ) Disabled Continue

( ) Other: ______________ Continue

( ) Don’t Know/Not Sure (DO NOT READ) Continue

( ) Refused (DO NOT READ) Continue

[Recruit a mix in each segment]

1a. Gender [Do not ask unless necessary]

( ) Male Continue

( ) Female Continue

[Recruit about half male and half female in each segment]

12a. What is your marital status?

( ) Married Continue

( ) Unmarried living with a partner Continue

( ) Divorced Continue

( ) Widowed Continue

( ) Separated, or Continue

( ) Single, never been married Continue

( ) Don’t Know/Not Sure (DO NOT READ) Continue

( ) Refused (DO NOT READ) Continue

[Recruit mix in each segment]

INVITATION

Thank you for answering my questions. I would like to tell you a little more about the discussion group. The group will meet on [Date(s) available at [Time(s) available] at [Describe remote process]. You will join up to 9 other people and a moderator. The group will meet for about 90 minutes. To show appreciation for your participation you will get $50.

Scheduled Date: _____________________ Time: ______________________

If you wear reading glasses or use a hearing aid, please remember to have them with you for the discussion.

Before we hang up, let me get the correct spelling of your name, and your address and phone numbers so we can send you a letter with directions and give you a reminder call the day of the group.

FULL NAME ____________________________________________

ADDRESS ____________________________________________

____________________________________________

E-MAIL ____________________________________________

CELL PHONE ____________________________________________

HOME PHONE____________________________________________

WORK PHONE____________________________________________

I must let you know that we do consider this to be a firm commitment on your part and we really expect to see you then. We are under obligation to our client to seat the correct number of participants in each group, so if you discover that you must cancel, please inform us at once so that we can replace you.

We will call/email you a day or two before your session just to confirm everything. Thank you again for your time and we will see you at the group.

Consumer Discussion Groups Recruitment Screener 1