Recruitment

Form Approved

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

CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)

Focus Groups Assessing the Uptake and Effectiveness of Inside Knowledge: Get the Facts About Gynecologic Cancer Campaign Materials

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 National Comprehensive Cancer Program name). On behalf of the federal Centers for Disease Control and Prevention, we are planning a focus group study with (insert the public or health care providers) about gynecologic cancers. Some people we speak with today will be invited to participate for about 2 hours of your time. (for the public, also read: to show appreciation you will receive a $15 gift card to local grocery store or coffee shop; for providers read: to show appreciation you will be eligible to earn continuing medical education credits).

Public: May I ask you a few questions?

1. Are you a woman 18 years of age or older?

1 No 2 Yes

If yes then go to INVITATION:

2. INVITATION:

Thank you. We are convening focus groups with the public 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... [insert schedule specifics]

Are you available?

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

If yes, then

Great…I will send you information with directions.

If no to question 1then go to INELIGIBLE:

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

Provider: May I ask you a few questions?

1. What is your primary specialty, that is, the specialty in which you spend 50% or more of your professional time?

 Family Practice  General Practice

 Internal Medicine  Obstetrician/Gynecologist

 Physician Assistant  Nurse

 Nurse practitioner

If any of the above, then go to number 2

If none of the above, then go to Ineligible

2. Do you currently provide care through direct interaction with female patients aged 18 and older on a regular basis?

1 No 2 Yes

If yes then go to INVITATION

If no then go to INELIGIBLE

3. INVITATION:

Thank you. We are convening focus groups with 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... [insert schedule specifics]

Are you available?

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

If yes, then

Great…I will send you information with directions.

If no then go to INELIGIBLE:

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

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