Recruitment Form

Form Approved

OMB No. 0920-0800
Expiration Date: 11/30/2014

CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)

Tailoring Gynecologic Cancer Education for Health Care Providers

Respondent Recruitment Form

GROUP DATE/TIME:_________________________________________________________

Name:________________________________________________________________________

Phone # +/or e-mail address for confirmation: ______________________________________

_______________________________________________________________________________

Address:

City, State: _____________________________________ZIP Code:

Public reporting burden for this collection of information is estimated to average 2 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0800).

Hello, my name is __ I’m with _______, (insert qualitative research firm description). On behalf of the federal Centers for Disease Control and Prevention, we are planning a focus group study with health care providers about gynecologic cancers. Some people we speak with today will be invited to participate in a focus group where light refreshments will be served, for about 60 minutes of your time. (if applicable- also read: You will receive a $35.00 gift card to a local coffee shop for your time).

May I ask you a few questions?

1. Are you currently a medical resident at (insert academic medical institution)?

 

1 No (if no go to question 2)

2 Yes

 

2. Are you currently employed as someone who supervises medical residents at (insert medical institution)?

1 No

2 Yes

If yes to either questions 1 or 2 go to INVITATION:

3. INVITATION:

Thank you for answering my questions. We are convening focus groups with health care providers to discuss gynecologic cancers. I hope you will be interested in participating. The focus group will take place nearby.

We would like to invite you to be in a group on... [See schedule]

Are you available?

1. No [Thank and end call.] 2 Yes

Great…I will send you a confirmation letter with directions.

4. If no to both questions 1 or 2 go to INELIGIBLE:

Thank you for answering my questions. Unfortunately you are not eligible to participate in these focus groups. Thank you so much for your time.

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