NHTSA Form 1190 Screener Guide for Tool Kit Review Focus Group Community

OMB Control No.: 2127-0682

Expiration Date: 01/31/2015

Recruitment Screening Guide for Community Focus Groups for Toolkit Review to Develop Materials to Increase Seat Belt Use among Recently Arrived Hispanic Immigrants

NOTES TO RECRUITER:

Age/Gender composition of each group: 18-40 (women and men)

For each group, recruit 12 participants (6 males& 6 females) anticipating that 9 will attend.

Hello, I’m from the National Latino Children’s Institute or local partner organization. A few weeks ago you participated in training on driver safety, especially the use of seat belts. We would like your opinions about the training session, materials used, and the information that you learned.

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. We are recruiting individuals to participate in a group discussion to give us feedback on the training and materials to increase seat belt use among recently arrived Hispanic immigrants. Are you interested in participating in such a discussion?

Yes	Continue
No	Terminate
Unsure/Refused	Terminate

2. One more question: How long have you been in the United States:

Five years or less	Continue
More than five years	Continue
Unsure/Refused	Terminate

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:

Thank you for agreeing to participate. This focus group is being conducted to collect information about the training, to help us improve or make any changes to the materials and the way the information is delivered. This collection of information is VOLUNTARY and will be used for formative purposes only so that we may edit the materials to increase the effectiveness of the toolkit. 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: 1190 2 | Page