NHTSA Form 1188 Screener Guide for Community Service Delivery Organizati

OMB Control No.: 2127-0682

Expiration Date: 01/31/2015

Recruitment Screening for Community Service Delivery Organizations Focus Groups to Develop Materials to Increase Seat Belt Use among Recently Arrived Hispanic Immigrants

NOTES TO RECRUITER:

Composition of each of two groups:

• Group 1: Community Service Delivery Organizations working with Hispanic recently arrived immigrants (5 years or less in U.S.)

• Group 2: Community Service Delivery Organizations working with Hispanic/Latino acculturated participants (more than 5 years in U.S.)

For each group, recruit 12 participants anticipating that 9 will attend. Attempt to recruit community service delivery organizations from a variety of the following sectors:

• Non-profit

• Business

• Community Clinics/Hospitals/Churches/Religious Organization

• Traffic Safety

Note organization contacted: ______________________________

Hello, I’m from the National Latino Children’s Institute or local partner organization, and I would like to invite you to participate in a focus or discussion group about ways to improve traffic safety in the community.

As a Community Service Delivery Organization, you provide services to the Hispanic population. We are interested in your views on how to deliver programs to this population.

This collection of information is VOLUNTARY and will be used to recruit individuals to participate in a focus group meeting. Public reporting burden for this survey is estimated to average 10 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. We will not collect any personal information that would allow anyone to identify you. Please note that a federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB control number. The OMB control number for this collection is 2127-0682. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590.

1. Do you work with Hispanics who are newly arrived or acculturated?

Newly Arrived	Continue
Acculturated	Continue
Both	Continue
Unsure/Refused	Terminate

2. We are interested in developing strategies to improve traffic safety and increase seat belt use among the Hispanic population and are recruiting individuals to participate in a group discussion to help develop materials and strategies to do this. We are interested in your ideas on how best to do this, especially as you are currently working with the Hispanic population. Are you interested in participating in such a discussion group?

Yes	Continue
No	Close
Unsure/Refused	Close

Termination Script

Thank you for taking the time to answer our questions.

If they don’t qualify add: Unfortunately, we’re looking for individuals with different experiences than you.

If they qualify, read:

This collection of information is VOLUNTARY and will be used for formative purposes only so that we may develop materials to increase seat belt use among recent Hispanic immigrants. We will not collect any personal information that would allow anyone to identify you.

I would like to invite you to be a part of this focus group. The focus group will take place on

Date: __________________________________ Time:_____________

Location: ______________________________________

For more information you can contact me by phone XXX-XXX-XXXX or via email. I look forward to speaking with you at the focus group.

NHTSA Form: 1188 2 | Page