Form Approved
OMB No. 0920-0919
Exp. Date 01/31/2015
[USE THE FOLLOWING TEXT IF ANSWERING CALL FROM POTENTIAL RESPONDENT:] Thank you for calling about the Children’s Health Project and for your interest in participating in the focus group for parents. In order to see if you’re eligible to participate, we just need to ask you a few questions. It shouldn’t take more than 5 minutes.
[USE THE FOLLOWING TEXT WHEN RETURNING A CALL FROM A POTENTIAL RESPONDENT:] I’m [NAME], calling from Westat. You called us recently and left a message about participating in a focus group as part of the Children’s Health Project. Thank you for your call. I have just a few questions for you to see if you’re eligible to participate. It shouldn’t take more than 5 minutes.
First, how old are you?
IF 18-55→ CONTINUE
IF <18 or >55 →THANK AND END [INELIGIBLE]
Are you the parent or guardian of a child?
IF YES → CONTINUE
IF NO →THANK AND END [INELIGIBLE]
How many children do you have?
ENTER NUMBER: __________
(IF >0, GO TO Q4, ELSE THANK AND END [INELIGIBLE])
How old [is your child/are your children]?
CHILD 1: __________
CHILD 2: __________
CHILD 3: __________
CHILD 4: __________
CHILD 5: __________
CHILD 6: __________
CHILD 7: __________
(IF ANY CHILDREN ARE AGES 5 OR YOUNGER, GO TO Q5, ELSE THANK AND END [INELIGIBLE])
Do you have a child who has been diagnosed as having a developmental delay or developmental disability (e.g., ADHD, Autism, Cerebral Palsy, hearing loss, vision impairment, etc.)?
IF YES → THANK AND END [INELIGIBLE]
IF NO → CONTINUE
Have you ever worked in the health or medical field (e.g., as a nurse, physician or medical assistant)?
IF YES → THANK AND END [INELIGIBLE]
IF NO → CONTINUE
Do you work in a clinic, hospital, or doctor’s office?
IF YES → THANK AND END [INELIGIBLE]
IF NO → CONTINUE
Do you work with children who have special needs or in special education?
IF YES → THANK AND END [INELIGIBLE]
IF NO → CONTINUE
What is the highest level of education you have completed?
Less than high school
High school diploma or GED
Technical college/Associates degree
Some college
College degree
Graduate degree
Are you comfortable speaking and reading in English?
Yes → CONTINUE
No → THANK AND END [INELIGIBLE]
Are you of Hispanic or Latino origin?
Yes
No
How would you describe your race? (Select all that apply.)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Refused
Which best describes your total household income?
Less than $15,000
$15,000 to $24,999
$25,000 to $34,999
$35,000 to $50,000
Over $50,000→ THANK AND END [INELIGIBLE]
[ELIGIBLE RESPONDENTS:] Thank you for answering those questions. You are eligible to participate in the study. Let me tell you the dates, times, and locations for our upcoming focus groups, so that we can find a time that works for you. [PROCEED TO SCHEDULING]
[INELIGIBLE RESPONDENT TERMINATION:] Thank you for answering those questions. Unfortunately you’re not eligible to participate in our study, but we appreciate your interest and your time today. Goodbye.
The public reporting burden of this collection of information is estimated to average 3 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 NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0919)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | [email protected] |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |