1 Screener

OMB No.: 0925-0645

Expiration Date: 12/31/2014

Public reporting burden for this collection of information is estimated to average 5 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0645). Do not return the completed form to this address.

– Participant Screener –

Thank you for calling about the research study. My name is and I'm calling from a local research firm working as a contractor to the National Cancer institute. We're doing research studies on values, goals, and physical activity, and I'd like to ask you a few quick questions. Based on the answers to these questions we will be inviting people to participate in a brief survey and focus group. You will receive $30 as a thank you after you have completed the study. Now I would like to ask you:

1. In the past year, have you participated in individual interviews or focus groups at Westat or other survey research companies?

• YES  INELIGIBLE

• NO

2. [RECORD GENDER. IF NOT OBVIOUS, ASK]

Are you male or female?

FEMALE :___:

[RECRUIT ONLY FEMALES]

MALE :___:

2. What is your age? CODE INTO ONE OF THE FOLLOWING CATEGORIES.

UNDER 20; :___: [TERMINATE]

20-35; :___:

36-50; :___: [RECRUIT A MIX OF AGES]

51-65; :___:  INELIGIBLE

OVER 65. :___:  INELIGIBLE

2. What is the highest grade in school that you have completed?

Less than high school; :___:

High school graduate; :___:

Some college (no degree)or some vocational training:__ [RECRUIT A MIX]

College graduate; Associates degree; or Completed vocational training:___:

Advanced degree. :___:

2. In terms of ethnicity, do you consider yourself (check one)?

Not Hispanic or Latino

Hispanic or Latino

2. What is your race (check one or more)?

White; :___:

Black or African American; :___:

Asian; :___:

Native Hawaiian or Other Pacific Islander; or :___: [RECRUIT A MIX]

American Indian or Alaska Native :___:

Next, I would like to ask you about your physical activity. Physical activity is activity where you move and increase your heart rate above its resting rate, and includes things such as using gym equipment, walking, swimming, or biking.

2. During a typical week, how many days are you physically active?

_______

When you are physically active, about how many minutes do you spend being active?

_______

IF SCREENED OUT OF STUDY:

We are not able to include you at the study at this time. Thank you for your interest.

IF SCREENED INTO STUDY:

Thank you for answering all my questions. I would like to schedule you to attend an interview at NCI on {DATE} at {TIME}. You will receive $30 as a thank you after you have completed the study. Is that a good time for you?

Great! I’d like to mail you information about how to get to our facility. May I have the correct spelling of your name and your address?

COLLECT RESPONDENT ADDRESS AND PHONE

Address: _____________________________________________________________

City: _________________________________ State: ______ Zip Code: __________

Phone: ________________________________________