Pediatrician Screener - word

Attachment E

Pediatrician Screener

Form Approved

OMB No. 0920-0572

Expiration Date: 2/28/2015

Public Reporting burden of this collection of information is estimated at 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 Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-0572).

Screener/Pediatricians

CDC “Parents are the Key” Toolkit Materials Evaluation

10-MINUTE ASSESSMENT TO RECRUIT FOR ONLINE FOCUS GROUPS

(INTRO) We would like to invite you to participate in an online group discussion [INSERT DATE]. The group session will last for approximately 60 minutes and will be conducted in English.

The session is being sponsored by the Centers for Disease Control and Prevention and is focused on a communications campaign about safe teen driving. The campaign highlights the message that motor vehicle crashes are the leading cause of death among teens, but there are proven steps that parents can take to help keep teens safer on the road. 

To express our appreciation for assisting us with your insights, we will offer a $75 gift for participation. But, first I'd like to ask you a few questions for background information to see if you qualify for this project. [TYPE: Static]

Overview:

20-25-person online focus group: 60 minute session

All will be:

• Pediatricians in practice for at least 2 years

• Clinicians consulting with patients at least weekly

• Pediatricians with at least 20% of patients being teens (13-18 years old)

Recruit a range of:

• Age

• Gender

• Geography

(RECRUIT1) Would you be available to participate in an online focus group on the day/time listed below? [TYPE: Multiple Choice]

1:	Yes, I would like to participate on [INSERT DATE & TIME]
2:	No [TERMINATE]

(S1. DEMOGRAPHICS GENDER) Are you... [TYPE: Multiple Choice]

1:	Male
2:	Female

(S2. DEMOGRAPHICS AGE) What is your approximate age? [TYPE: Multiple Choice]

1:	18-24 years [TERMINATE]
2:	25-29 years [TERMINATE]
3:	30-34 years
4:	35-39 years
5:	40-44 years
6:	45-49 years
7:	50-54 years
8:	55-59 years
9:	60-64 years
10:	65-69 years
11:	70-74 years
12:	75 and over [TERMINATE]

(S3. DEMOGRAPHICS AREA EMPLOY) You previously indicated that you are a physician in the healthcare industry. Which of the following best describes your specialty? [TYPE: Multiple Choice]

1:	General practitioner [TERMINATE]
2:	Family physician [TERMINATE]
3:	Pediatrician
4:	Nurse practitioner [TERMINATE]
5:	Psychiatrist / Psychologist [TERMINATE]
9:	Other [TERMINATE]

(S4. DEMOGRAPHICS CLINICIAN) Which of the following best describes your current job ... [TYPE: Multiple Choice]

1:	Clinician operating private practice
2:	Clinician working for group practice
3:	Clinician working for a hospital or clinic
4:	Researcher – clinical [TERMINATE]
5:	Other (please specify)

(S5. DEMOGRAPHICS YEARS IN PRACTICE) How long have you been a practicing doctor? [TYPE: Multiple Choice]

1:	1 year or less [TERMINATE]
2:	2 to 5 years
3:	6 to 10 years
4:	11 to 15 years
5:	16+ years

(S6. DEMOGRAPHICS CONSULT) How often do you consult with patients? [TYPE: Multiple Choice]

1:	Daily
2:	Weekly
3:	Monthly [TERMINATE]
4:	Less than once per month [TERMINATE]

(S7. DEMOGRAPHICS AGE OF PATIENTS) What percentage of your patients fall into each of the below age groups? [TYPE: Must add up to 100%]

1:	Under 5	_____%
2:	6-12 years old	_____%
3:	13-18 years old	_____%[TERMINATE if less than 20%]
4:	19 and older	_____%

(S8. DEMOGRAPHICS STATE) What state do you reside in? [TYPE: Multiple Choice]

1:	Alabama
2:	Alaska
3:	Arizona
4:	Arkansas
5:	California
6:	Colorado
7:	Connecticut
8:	Delaware
9:	District of Columbia
10:	Florida
11:	Georgia
12:	Hawaii
13:	Idaho
14:	Illinois
15:	Indiana
16:	Iowa
17:	Kansas
18:	Kentucky
19:	Louisiana
20:	Maine
21:	Maryland
22:	Massachusetts
23:	Michigan
24:	Minnesota
25:	Mississippi
26:	Missouri
27:	Montana
28:	Nebraska
29:	Nevada
30:	New Hampshire
31:	New Jersey
32:	New Mexico
33:	New York
34:	North Carolina
35:	North Dakota
36:	Ohio
37:	Oklahoma
38:	Oregon
39:	Pennsylvania
40:	Rhode Island
41:	South Carolina
42:	South Dakota
43:	Tennessee
44:	Texas
45:	Utah
46:	Vermont
47:	Virginia
48:	Washington
49:	West Virginia
50:	Wisconsin
51:	Wyoming

(FLASH CHECK) You will need to have the Flash player installed on your system in order to join the live session.

Please click here to make sure you have Flash.

If you do not, then follow the instructions to install Flash and return to this page. If you do, then select 'Yes' below and click the Next button. [TYPE: Multiple Choice]

1:	Yes, I have Flash!
2:	No [TERMINATE]

(CONNECTION CHECK) What type of internet connection do you currently have on the computer you will be using to participate in the online discussion session? [TYPE: Multiple Choice]

1:	Dial-up connection [TERMINATE]
2:	Broadband connection (e.g., cable, DSL, Fios, etc.)

(THURS RECRUIT) Congratulations! You have agreed to participate in a live online session on ...

[INSERT DATE & TIME]

 

• Prior to the session, you will receive an email confirmation from 'Stratalys Research' with a link and instructions for logging into the session.

• You may log in up to 20 minutes before the start time of the session. You will not be allowed into the session if you log in late.

• You may participate from any desktop or laptop computer.

• NOTE: Please make sure you can devote the entire 60 minutes to the session. You must complete the entire session in order to receive your reward. Also, please try to ensure that you are able to focus on the session by eliminating any distractions.

Please confirm that you will be participating by selecting 'Yes' below...

 [TYPE: Multiple Choice]

1:	Yes, I'll be participating
2:	No [TERMINATE]

(COMPLETE) Thank you for completing the online focus group registration! You will receive an email with login information on the day of the session. We look forward to your participation. Please click on the link below to submit your answers...

[TYPE: Static]

(OVERQUOTA) Thank you for participating! We needed a specific number of people to take part in the discussion session, and we have already exceeded that number! Although we have reached our limit for the group session, we appreciate your time.

Please click on the link below to submit your answers...
[TYPE: Static]

(TERMINATE) Thank you for participating! Although you did not qualify for this study, we appreciate your time. Thanks again!

Please click on the link below to submit your answers...
[TYPE: Static]

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