Form 1 Household Screening Interview for Telephone Interviewing

ATTACHMENT 2a.

Household Screening Interview

Form Approved

OMB No. 0920-0805

Exp. Date 2/29/2012

Household Screening Interview for Telephone Interviewing

Public reporting burden of this collection of information is estimated to average 3 minutes per response, including the time 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 current 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 (0920-0805).

PREAMBLE

Hello, I’m _________________ calling on behalf of the Centers for Disease Control and Prevention [IF COMMUNITY =12 FILL "and for the Inter-Tribal Council of Michigan"]. I’m calling residents of [IF ENGLISH FILL LOCALITY1. ELSE IF SPANISH FILL LOCALITY1_SP. ELSE IF HAITIAN CREOLE FILL LOCALITY1_HC.] about a study on health in your community.

READ IF NECESSARY: We are collecting data to better understand health related behaviors and diseases that may affect adults in your neighborhood. Researchers are trying to understand the health issues specific to your neighborhood, so programs can better fit the needs of the people living there. NORC is conducting this survey for the Centers for Disease Control and Prevention (CDC).

1. Continue [GO TO LANG_TYPE]

2. Confirm business [GO TO SALZ]

3. Out of scope [GO TO THANK_YOU_OOS]

4. Terminate the Interview [GO TO T1]

5. Cell Phone [GO TO S_DRIVE AND SET CELL_PHONE FLAG = 1]

6. Answering Machine [FILL] [If message is to be left then GO TO SASERV else hang up and set ITS =35, 36 or 37]

7. R will call 800 Line/Verify website [GO TO VERIFY_INFO, set ITS =69]

8. R asks for letter [GO TO M1_NAME]

9. Supervisor Review (Raise your hand to get permission before using this code) [set ITS =49]

IF CASE FLAGGED AS CELL PHONE IN SAMPLE, GO TO S_DRIVE AFTER PREAMBLE

PREAMBLE1

We'd still like to talk to you because your opinions are important.

1. Continue [GO TO LANG_TYPE]

PREAMBLE_2

Hello, I’m _________________ calling on behalf of the Centers for Disease Control and Prevention [IF COMMUNITY =12 FILL "and for the Inter-Tribal Council of Michigan"]. I’m calling residents of [FILL LOCALITY1] about a study on health in your community.

READ IF NECESSARY: We are collecting data to better understand health related behaviors and diseases that may affect adults in your neighborhood. Researchers are trying to understand the health issues specific to your neighborhood, so programs can better fit the needs of the people living there. NORC is conducting this survey for the Centers for Disease Control and Prevention (CDC).

1.Continue (back HH_NUM)

2. Confirm Business GO TO SALZ

3. Out of scope - GO TO THANK_YOU_OOS

4. Terminate the Interview - GO TO T1

5. Cell Phone - GO TO S_DRIVE AND SET CELL_PHONE FLAG = 1

7. R will call 800 Line/Verify website - GO TO VERIFY_INFO set ITS =69

8. R asks for letter - GO TO M1_NAME

9. Supervisor Review (Raise your hand to get permission before using this code) - set ITS =49

LANG_TYPE

IWER: WHAT LANGUAGE IS NEEDED TO CONDUCT THIS INTERVIEW?

1. ENGLISH

2. SPANISH

3. VIETNAMESE

4. KHMER

5. MANDARIN

6. HAITIAN CREOLE

7. KOREAN

8. ANOTHER LANGUAGE

[all go to LL_END]

LL_END

IF LANG_TYPE = 1,2, 3, 4, 5, 6 OR 7 AND INTERVIEWER DOES NOT HAVE APPROPRIATE LANGUAGE ATTRIBUTE DISPLAY:

Thank you very much. We will call back. Goodbye.

AND SCHEDULE FOR GENERAL CALL BACK.

ELSE IF

((LANG_TYPE = 1,2,3, 4, 5, 6 OR 7 AND INTERVIEWER HAS APPROPRIATE ATTRIBUTE) AND CELL_FLAG=1) --> GO TO S_DRIVE

ELSE IF

((LANG_TYPE = 1,2,3, 4, 5, 6, OR 7 AND INTERVIEWER HAS APPROPRIATE ATTRIBUTE) AND CELL_FLAG <>1)--> CONTINUE TO OVER18

ELSE IF LANG_TYPE = 8, DISPLAY:

Thank you very much. Goodbye.

AND GO TO UE QUESTION L1.

OVER_18

Am I speaking to someone who lives in this household who is 18 years old or older?

IF THE RESPONDENT SAYS NO: ASK TO SPEAK WITH SOMEONE 18 OR OLDER WHO LIVES IN THE HOUSEHOLD.

1. I AM THAT PERSON [GO TO ADVLET]

2. NEW PERSON COMES TO PHONE [GO TO PREAMBLE_2]

3. DOESN’T LIVE IN HOUSEHOLD [GO TO OVER18_CHECKPOINT]

4. NO PERSON AT HOME who is over 18 [GO TO OVER18_HH]

   99. REFUSED [GO TO REFUSAL CONVERSION, SET DISP AND TERMINATE]

OVER18_CHECKPOINT

ASK FOR ANOTHER PERSON OR SCHEDULE APPOINTMENT ON THE NEXT SCREEN

OVER18_HH

Does anyone live in your household who is 18 years old or older?

IF THE RESPONDENT SAYS NO, READ: “Just to clarify, no one 18 years of age or older lives in this household?”

1. YES, They are coming to the phone [GO TO PREAMBLE_2]

2. YES, But no one is home, so set a callback [GO TO CB1]

3. NO, No adults live in the household at any time

99. REFUSED [GO TO R1]

If OVER18_HH =3 and ADRSSCONF_FLAG =1 --> GO TO ADRSSCONF

ELSE

If OVER18_HH =3 and ADRSSCONF_FLAG =0 --> GO TO CLOSE

ADVLET

A letter about this study was sent out. Do you remember seeing this?

INTERVIEWER NOTE: The letter was sent in a business-sized envelope from the Department of Health and Human Services. The letter was printed on Department of Health and Human Services letterhead with a blue logo in the top left corner. The logo looks like outlines of a bird and faces inside of a circle.

1. YES
2. NO
77. DON'T KNOW
99. REFUSED

ASK ADVLET IF ADVLET_FLAG=1

IF PH_SOURCE =7 GO TO NUM_HH

ADRSSCONF

Just to check – we sent the letter to [FILL POSTAL ADDRESS]. Is that still your address?

1. YES
2. NO [GO TO CLOSE]
77. DON'T KNOW
99. REFUSED

ASK ADRSSCONF IF ADRSSCONF_FLAG=1

If 77 or 99, then continue interview.

NUM_HH

In order to scientifically select a member of your household, I need to ask how many people in your household are 18 years old or older?

Include yourself, but do not include adult family members currently living elsewhere, college students away at school, or anyone in a prison, mental hospital, or nursing home.

|___|___| NUMBER OF ADULTS
77. DON'T KNOW [GO TO ASK_ANOTHER]
99. REFUSE [GO TO REF_AVT]

Limit of 9

If NUM_HH =0 --> GO TO CLOSE

NUM_HH should be able to be changed from 77 or 99 if R later consents to the interview.

ASK_ANOTHER

Is there anyone in your household who knows how many people are 18 years old or older?

1. NEW PERSON COMES TO PHONE [GO TO PREAMBLE]
2. NO [GO TO TERM]

REF_AVT

We need to ask how many adults are in your household so that we know how many questions to ask.

1. CONTINUE [RETURN TO NUM_HH]
2. END CALL [GO TO TERM]

HOUSEHOLD_ROSTER

SCREENER PROGRAMMING WILL GUIDE INTERVIEWER TO REPEAT EACH QUESTION FOR EACH HOUSEHOLD MEMBER BEFORE MOVING TO NEXT QUESTION.

FNAME_A

[If NUM_HH = 1]
For this study, we need to interview certain types of people, so, next I will be asking you about your [IF COMMUNITY 11, 22, 23FILL WITH 'gender, age and race'; ELSE FILL WITH 'age and race' ]. May I have just your first name or initials?

[If NUM_HH > 1]
For this study, we need to interview certain types of people, so, next I will be asking you about the [IF COMMUNITY 11, 22, 23 FILL WITH 'gender, age and race'; ELSE FILL WITH 'age and race' ] of the [FILL NUM_HH] adults in your household. Starting with yourself, may I have just your first name or initials?

|______________|

99. REFUSE [GO TO INIT_X]

IF X=1 ASK FNAME_A

FNAME_X

[If NUM_HH > 1]

Could I please have the first name or initials of the [SECOND, THIRD, FOURTH, FIFTH] person who presently lives in the household?

|______________|

99. REFUSE [GO TO INIT_X]

IF X>1 ASK FNAME_X

IF NO NAME OR INITIALS, USE GENDER AND AGE BRACKET TO IDENTIFY THE HHM.

GENDER_X

INTERVIEWER: ASK THIS QUESTION OF INFORMANT ONLY IF YOU CANNOT TELL IF THE PERSON IS MALE OR FEMALE

[Are you/Is NAME OF FIRST HH MEMBER/ NAME OF SECOND HH MEMBER/ ETC.] male or female?

1. MALE
2. FEMALE
77. DON’T KNOW
99. REFUSED

IF REFUSED OR DON'T KNOW, SAVE THE RESPONSE GIVEN BUT ASSUME HH MEMBER IS MALE.

IF REFUSED OR DON'T KNOW DO NOT USE RESPONSES TO THIS QUESTION FOR ANY FILLS.

AGECAT_X

[Are you/Is NAME OF FIRST HH MEMBER/ NAME OF SECOND HH MEMBER/ ETC.] ...

1. 18-39 years old
2. 40-64 or
3. 65 or older|
4. LESS THAN 18 YEARS OLD
77. DON’T KNOW
99. REFUSED

IF LESS THAN 18 YEARS OLD, MEMBER DOES NOT QUALIFY AND SHOULD NOT BE SELECTED IN THE ALGORITHM.

SPAN_X

[Are you / Is NAME OF FIRST HH MEMBER/ NAME OF SECOND HH MEMBER/ ETC.] Hispanic or Latino?

1. YES
2. NO
3. ALL HH MEMBERS HISPANIC

4. NONE OF HH MEMBERS HISPANIC
77. DON’T KNOW
99. REFUSE

If 3 'all HH members are Hispanic' is chosen, then fill all SPAN_ roster spots with 1.

If 4 'none of HH members are Hispanic' then fill all SPAN_X roster spots with 2.

ASK IF COMMUNITY = 01, 06, 08, 09, 10, 11, 13, 18, 21, 24, 25, 26, 27.

RACE_X

Which of the following describes [your / NAME OF FIRST HH MEMBER/'S NAME OF SECOND HH MEMBER/ ETC.] race?

PLEASE READ ALL FOR FIRST HH MEMBER THEN READ AS NEEDED
SELECT ALL THAT APPLY

1. White/Caucasian
2. Black/African American
3. Asian
4. Native Hawaiian/Pacific Islander
5. American Indian/Alaskan Native
77. DON'T KNOW
99. REFUSE

NOTE: The labels that are displayed on the screen may vary depending on the community, but all responses need to code back to what is shown below.

RACE_SAME_X

7. ALL HH MEMBERS ARE SAME RACE
8. Continue

IF 'ALL HH MEMBERS ARE SAME RACE' IS SELECTED, THEN FILL ALL RACE_ ROSTER SPOTS WITH THE SAME VALUES

IF 7 'ALL HH MEMBERS ARE SAME RACE' THEN FILL ALL RACE_X ROSTER SPOTS WITH RACE_X RESPONSE

ASIAGRP_ X

To what Asian group [do/does] [you/NAME OF FIRST HH MEMBER/ NAME OF SECOND HH MEMBER/ ETC.] belong?

1. Cambodian
2. Chinese
3. Filipino
4. Laotian
5. Thai
6. Vietnamese
7. Hmong
8. Korean

9. Asian Indian77. DON'T KNOW
99. REFUSE

ASK IF COMMUNITY = 05, 23 AND RACE_X = 3. ASIAN

ASIAGRP_SAME_X

APPEARS ON SAME SCREEN WITH ASIAGRP:

7. ALL HH MEMBERS BELONG TO SAME ASIAN GROUP
8. Continue

IF 'ALL HH MEMBERS BELONG TO SAME ASIAN GROUP' SELECTED, THEN FILL ALL ASIAGRP_ ROSTER SPOTS WITH THE SAME VALUES

IF 7 'ALL HH MEMBERS ARE SAME RACE' THEN FILL ALL ASIAGRP_X ROSTER SPOTS WITH ASIAGRP_X RESPONSE

HAWAIIGRP_X

To what Native Hawaiian/ Pacific Islander group do [YOU]/ does [NAME OF FIRST HH MEMBER/ NAME OF SECOND HH MEMBER/ ETC.] belong?

1. Native Hawaiian

2. Chamorro or Guamanian

3. Samoan

4. Tongan

5. Marshallese

6. Other Pacific Islander

77. DON'T KNOW

99. REFUSE

ASK IF COMMUNITY = 05 or 23 AND RACE_X = 4. NATIVE HAWAIIAN/PACIFIC ISLANDER

HAWAIIGRP_SAME_X

APPEARS ON SAME SCREEN WITH HAWAIIGRP:

7. ALL HH MEMBERS BELONG TO SAME HAWAIIAN/PACIFIC
8. Continue

IF 'ALL HH MEMBERS BELONG TO SAME HAWAIIAN/PACIFIC' IS CHOSEN, THEN FILL ALL HAWAIIGRP_ ROSTER SPOTS WITH THE SAME VALUES

IF 7 'ALL HH MEMBERS ARE SAME RACE' THEN FILL ALL HAWAIIGRP_X ROSTER SPOTS WITH HAWAIIGRP_X RESPONSE

LOOPOUT

CONFIRM THAT ALL HOUSEHOLD MEMBERS HAVE BEEN ROSTERED BEFORE CONTINUING, SAY:

Just to confirm, I have listed [FILL NUMBER] adults. Is this the correct number of adults over 18 living in your household?"

1. YES [GO TO SPHONE1]

2. NO [GO TO ADDMEM)

77. DON'T KNOW

99. REFUSE

ADDMEM

How many adults 18 years old and older live in your household?

|___|

99. REFUSE

Subtract the value given at ADDMEM from NUM_HH. The result is a positive integer, the remainder will determine how many extra HH members to ask about when CATI returns to the household roster variables. When returning to the household roster variables to add new HH members, CATI should begin at the first blank roster number for name, age, span, race and haitian. When adding new HH members X = the last ordinal number used in the original loop +1. IF the result is a negative integer (i.e., they indicate that they rostered too many people), display a grid that lists the persons currently rostered.

If informant wants to delete a HH member from the roster, we should display a grid that shows the roster and allows interviewer to select the HH member to remove from the roster. If a member is to be removed from the roster, set flag IGNORE to indicate which roster position should be ignored during the respondent selection process and change ELIGIBILITY to 0. The data in the roster positions that are being ignored should not be erased.

CLOSE

I'm sorry, but no one in your household was selected to participate at this time. I want to thank you for the time spent answering my questions. If you have any further questions about this survey I can give you a toll free number to call for more information (877-375-5964).

IWER: IF NO ONE SELECTED, AND R ASKS WHY READ:

(I appreciate your interest in participating/I appreciate your question about why you were not selected).  Our computer system selects households and household members to participate in the study.  Because the computer system did not select anyone in your household, those are all the questions I have for you today.  Thank you for your time.

READ IF NECESSARY: The CDC routinely conducts studies on health care and health  issues in the general population, in specific communities and for  particular groups.  The computer system selects households for participation for this study based on a number of factors.  The CDC will use these data to improve the overall health of your community and the nation.   Because the computer system did not select anyone in your household, those are all the questions I have for you today.  Thank you for your time.

READ IF NECESSARY: I understand your concern about the selection process for the study.  If you would like to discuss the process further, I can give you the name and telephone number of the study sponsor:  Dr. Youlian Liao at 1-888-637-1563.

1. CONTINUE [Go to PN2]

PN2

Thanks again. Goodbye.

SPHONE 1

The computer has selected
[list all people]
to participate in this interview. [If PHONEN <> NULL Fill ("Can [IF NUMBER SELECTED = 1, FILL 'this person'; ELSE IF NUMBER SELECTED >1 FILL 'all these people'] be reached at this phone number, [FILL PHONE NUMBER]?" )]

1. YES [GO TO SELECTED]
2. NO [SPHONE 2_X]
77. DON'T KNOW [GO TO SELECTED]
99. REFUSE [GO TO SELECTED]

SPHONE 2_X

Can [NAME OF NUM_HH_X] be reached at this phone number [FILL PHONE NUMBER]?

1. YES [GO TO SPHONE 2_X +1]
2. NO [SPHONE 3_X]
77. DON'T KNOW [GO TO SPHONE 2_X +1]

99. REFUSE [GO TO SPHONE 2_X +1]

SPHONE 3_X

What is the best number I should call to reach [FNAME_X]?

|___|___|___|___|___|___|___|___|___|___| [ENTER 10 DIGIT NUMBER] [GO TO SPHONE4_X]

77. DON'T KNOW [GO TO SPHONE 2_X +1]
99. REFUSED [GO TO SPHONE2_X +1]

SPHONE 4_X

Is this a cell phone number?

1. YES [GO TO SPHONE2_X+1]

2. NO [GO TO SPHONE 2_X +1]
77. DON'T KNOW [GO TO SPHONE 2_X+1]
99. REFUSED [GO TO SPHONE 2_X+1]

SPHONE 5

Just to confirm, I can reach

[NAME OF NUM_HH_X] at [fill phone number].

[NAME OF NUM_HH_X+1] at [fill phone number].

[etc, until all phone numbers and people are accounted for. Then continue with interview]

1. YES [GO TO SELECTED]
2. NO [RETURN TO SPHONE 2_X]

If NO, limit Loop to 2Times.

If limit reached 2 and SPHONE = NO THEN continue to Selected

SELECTED

THE FOLLOWING PEOPLE ARE ELIGIBLE FOR THE SURVEY:

* [SELECTED RESPONDENT 1] [AGE]

[SELECTED RESPONDENT 2] [AGE]

[ETC.]

[IF INFORMANT IS SELECTED, DISPLAY:

INFORMANT IS SELECTED.

INFORM HIM/HER THAT HE/SHE HAS BEEN SELECTED TO BE INTERVIEWED, AND GO TO THE QUESTIONNAIRE.

IF INFORMANT IS NOT AVAILABLE, ASK TO SPEAK TO THE NEXT SELECTED PERSON AND GO TO THE QUESTIONNAIRE]

[IF INFORMANT IS NOT SELECTED, DISPLAY:

INFORMANT IS NOT SELECTED.

ASK TO SPEAK WITH THE FIRST SELECTED RESPONDENT AND GO TO THE QUESTIONNAIRE.

IF FIRST SELECTED RESPONDENT IS NOT AVAILABLE, ASK TO SPEAK TO THE NEXT SELECTED PERSON AND GO TO THE QUESTIONNAIRE.]

The person completing the roster will display *** in front of the name

SALZ

Is this telephone number for business use only?

1. YES [GO TO SALZ_BUS]

2. NO [GO TO PREAMBLE]

3. DORM/PRISON/HOSTEL [GO TO SADDCONF THEN BUS_EXIT]

4. PAGING SERVICE [GO TO SADDCONF THEN BUS_EXIT]

SALZ_BUS

Is this a home business?

1. YES [GO TO PREAMBLE1]

2. NO, COMMERCIAL BUSINESS [GO TO SADDCONF]

3. DORM/PRISON/HOSTEL [GO TO SADDCONF THEN BUS_EXIT]

4. PAGING SERVICE [GO TO SADDCONF THEN BUS_EXIT]

S_DRIVE

If you are currently driving a car or doing any activity that requires your full attention, I need to call you back at a later time.

1. CONTINUE [GO TO OVER18]

2. R IS DRIVING [GO TO S_ATTN]

3. CALL BACK ANOTHER TIME [GO TO S_ATTN]

SADDCONF

Just to check – we sent the letter to [FILL POSTAL ADDRESS]. Is that still your address?

1. YES [GO TO BUS_EXIT]

2. NO [GO TO BUS_EXIT]

77. DON'T KNOW [GO TO BUS_EXIT]

99. REFUSED [GO TO BUS_EXIT]

BUS_EXIT

We are interviewing only residences. Thank you very much.

S_ATTN

For your safety, we will call you back at another time.
[TERMINATE INTERVIEW GO TO CB1]

SASERV

BASED ON THE ANSWERING SERVICE, WAS THIS DEFINITELY A BUSINESS, A HOUSEHOLD, OR COULD NOT BE DETERMINED?

1. BUSINESS [TERMINATE]
2. HOUSEHOLD [TERMINATE]
3. COULD NOT DETERMINE [TERMINATE]
4. ANSWERING MACHINE SAID "TAKE ME OFF YOUR LIST" [TERMINATE]

TERM

Thank you for your time. Goodbye.