Screener Baltimore Male 18-39

Attachment 6 -RECENTLY HOSPITALIZED FOCUS GROUP SCREENER (Ages 18-39)

(Westat – DVT/PE)

June 11, 2012

Baltimore, MD

Criteria for focus group:

• 8-9 participants per focus group, recruit 12

• Male only group

• Ages 18-39

• No family history or stroke or DVT

• Any race/ethnicity but some diversity in groups

• High School Graduate or higher

• Hospital stay in the last 12 months: surgery, trauma (falls, car accidents), cancer treatment

NOTES TO FACILITY

• Please do not call people with medical or health-related occupations

• Please do not call people who have done a focus group in the last 6 months.

• Please do not call people who have ever done 5 or more focus groups.

• Please do not call people who participated in this study previously.

• Accept maximum of 3 recruits that are never married, divorced or separated AND no children.

Hello. My name is _____ of _______, a local marketing research firm. We are recruiting participants for a research study about health issues for the Centers for Disease Control and Prevention (CDC). Participants in this study will receive $75 (8:00 p.m. group). Let me assure you that this is a legitimate research study. I am not trying to sell anything. I have just a couple of questions to see if you qualify for the study.

1. RECORD GENDER

( ) Female – THANK & TERMINATE.

( ) Male – CONTINUE.

2. Please stop me when I mention the group that includes your age.

( ) 18 – 24 – CONTINUE.

( ) 25 – 29 – CONTINUE.

( ) 30 – 39 – CONTINUE.

( ) 40 – 49 – THANK & TERMINATE.

( ) 50 – 64 – THANK & TERMINATE.

( ) 65 – 74 – THANK & TERMINATE.

( ) 75 – 80 – THANK & TERMINATE.

( ) 81 and older – THANK & TERMINATE.

( ) Refused – THANK & TERMINATE.

3. Are you: [RECRUIT A MIX] (see notes to facility)

( ) Married

( ) Never married

( ) Divorced or separated

( ) Widowed

( ) Partnered (or living with a domestic partner)

( ) Refused – THANK & TERMINATE.

4. How many children do you have?______ (see notes to facility)

STOP.

ACCEPT A MAXIMUM OF 3 RECRUITS THAT ARE NEVER MARRIED, DIVORCED/SEPARATED OR WIDOWED IN Q3, AND NO CHILDREN IN Q4. ELSE CONTINUE.

5. In the past 12 months, have you been hospitalized for any of the following medical conditions?

		YES	NO
A	Fracture or broken bones?	 CONTINUE	 CONTINUE
B	Surgery?	 CONTINUE	 CONTINUE
C	An injury or accident that required an overnight hospital stay?	 CONTINUE	 CONTINUE
D	Cancer treatment?	 CONTINUE	 CONTINUE

5. In the past 12 months, have you had a hospital stay of 3 or more days?

( ) Yes – CONTINUE

( ) No – CONTINUE

( ) Refused – THANK & TERMINATE

5. Do you currently smoke cigarettes?

( ) Yes – CONTINUE

( ) No – CONTINUE

( ) Refused – THANK & TERMINATE

5. Have you or a close family member ever had any of the following medical conditions?

		YES	NO
A	Stroke	 THANK & TERMINATE	 CONTINUE
B	High blood pressure	 CONTINUE	 CONTINUE
C	Deep vein thrombosis, or DVT	 THANK & TERMINATE	 CONTINUE
D	Anemia	 CONTINUE	 CONTINUE

5. What is the last year of school or college you have completed? [RECRUIT A MIX]

( ) Less than High School – THANK & TERMINATE

( ) High School grad – CONTINUE

( ) Some college – CONTINUE

( ) 4-year college graduate – CONTINUE

( ) Graduate school – CONTINUE

( ) Refused – THANK & TERMINATE

5. Are you currently employed?

( ) Yes

( ) No [MAXIMUM 3 RECRUITS]

5. Do you have any difficulty reading in English?

( ) Yes – THANK & TERMINATE.

( ) No

5. How many focus groups have you ever participated in?____ [THANK & TERMINATE IF 5+]

5. Do you or anyone in your household work for an advertising agency, marketing or marketing research firm?

( ) Yes – THANK & TERMINATE.

( ) No

5. Do you or anyone in your household work for any business or organization involved in health or healthcare?

( ) Yes – THANK & TERMINATE.

( ) No

5. Are you of Hispanic or Latino origin?

( ) Yes

( ) No

5. Finally, what is your race? [CHECK ALL THAT APPLY]

( ) American Indian or Alaska Native – CONTINUE

( ) Asian – CONTINUE

( ) Black or African American – [RECRUIT AT LEAST 3]

( ) Native Hawaiian or Other Pacific Islander – CONTINUE

( ) White – [RECRUIT AT LEAST 3]

( ) Refused – THANK & TERMINATE.

READ THE FOLLOWING:

I’d like to invite you to take part in a research study that takes the form of a group discussion. The discussion will be held on June 11^th and will last about 90 minutes. No one will try to sell you anything in this discussion and no one will contact you for any sales purpose as a result of your participation in this study. We are only interested in your opinions and, as I mentioned earlier, you will receive $75 (8:00 p.m. group) for taking part in this study.

If you need them, please remember to bring your reading glasses.

(X) [8:00 p.m.]. A light snack will be served.

GIVE RESPONDENT DIRECTIONS TO FACILITY. We will call you the day before to remind you about this discussion. We will be counting on your attendance since we will only be inviting about ten people. So that we can be sure to start and end on time, please plan to arrive at our office fifteen minutes before the beginning of the group. We are counting on your participation, so please be sure to contact us as soon as possible if something arises and you find you can’t attend.

May I please get your:

Name: _________________________________________________________________________

Address: ________________________________ City:_________________ Zip: _____________

Where do you prefer to be called?

( ) Home Phone: ____________ ( ) Work Phone: ____________ ( ) Cell Phone: ____________

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