Michigan Scheduling Questionnaire

Attachment 4b

MICHIGAN DEPARTMENT OF COMMUNITY HEALTH

DIVISION OF ENVIRONMENTAL HEALTH

Biomonitoring of Persistent Toxic Substances

in Michigan Urban Fisheaters

Telephone Questionnaire for Scheduling Appointments

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Form Approved

OMB No. 0923-XXXX

Exp. Date/xx/xx/20xx

Note to scheduler: The text in italics and unbold font is instructional or supporting information. Do not read aloud. CIRCLE or WRITE in answers.

Hello. My name is (first name). I am with the Fisheaters Study from the Michigan Department of Community Health. Recently, you were fishing on the {name of water body} and talked to someone from Wayne State University about a study that we are working on. We are looking at the amount of chemicals in people who eat fish that are caught from {name of water body}. You answered some questions and were interested in being in the study. Are you still interested?

If NO: That’s fine. Thank you for taking the time to talk with me today.

If YES: Great! Let me first make sure I have your correct name and other information.

1. What is your full name? VERIFY spelling

First: ______________________________

Middle initial:_______________________

Last:_______________________________

2. What is your mailing address?

Street Number: _ Street Name:__ _________________

Unit: ______________ or P.O. Box: ________________________

City: _______________ __________ State: _______ ZIP Code: ___________

Public reporting burden of this collection of information is estimated to average 7 minutes) per response for total participation, 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 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0923-XXXX).

3. Do you have an email address that I could use to contact you?

Email address: ___________________________________________________

4. I just called you at XXX- XXX-XXXX. READ participant’s phone number. Is this the best phone number to reach you? If YES, SKIP to Q 6.

[ ] Yes

[ ] No

5. Do you have another number where I could reach you?

Phone 1: ___________________________ Home  Work  Cell

Phone 2:___________________________ Home  Work  Cell

Phone 3:___________________________ Relative/friend’s name: ________________

Now I need to ask you a few questions to find out if you can be part of the study.

6. How old are you?

__________ years

If less than 18 years old, person is not eligible. READ the Ineligible Age Script

(Ineligible Age Script)

I’m sorry but you are not old enough to be in the study. You must be 18 years old or older to be included. Thank you for taking the time to talk to me today.

If 18 years old or older, continue.

7. On average, how many meals of fish caught from the {Saginaw AOC/Detroit AOC} do you eat per month?

________ meals per month

If less than two meals per month, go to Ineligible Fish Eater Script

(Ineligible Fish Eater script)

I’m sorry; in order to be part of this study you must eat at least 2 meals per month of fish that are caught from the {Saginaw AOC/Detroit AOC}. Thank you for taking the time to talk to me today.

8. Do you have hemophilia or any other blood clotting or bleeding health problem?

[ ] Yes READ Ineligible Blood Health Problem Script

[ ] No

(Ineligible Blood Health Problem script)

I’m sorry but we cannot include anyone with a blood health problem in the study. You would not be able to give us a blood sample. Thank you for taking the time to talk to me today.

9. Have you had chemotherapy in the past 6 weeks?

[ ] Yes READ Ineligible Due to Chemotherapy Script

[ ] No

(Ineligible Due to Chemotherapy script)

I’m sorry but we cannot include anyone who has had chemotherapy in the past 6 weeks. You would not be able to give the amount of blood needed for this study. Thank you for taking the time to talk to me today.

10. Do you weigh less than 95 pounds?

[ ] Yes READ Ineligible Weight Script

[ ] No

(Ineligible Weight script)

I’m sorry but we cannot include anyone who weighs less than 95 pounds in the study. You would not be able to give the amount of blood needed for this study. Thank you for taking the time to talk to me today.

11. Have you lost more than 15 pounds In the last year?

[ ] Yes READ Ineligible Weight Loss Script

[ ] No

(Ineligible Weight Loss script)

I’m sorry but we cannot include anyone who has lost more than 15 pounds in the last year in the study. Weight loss could affect the amount of chemicals in your blood. Thank you for taking the time to talk to me today.

Questions 15 and 16 are for females. SKIP to Q 16 for males. If unsure of gender, READ Gender script.

(Gender script)

The next questions are for females. Wait for response indicating gender. If no response, ask his/her gender.

12. Indicate whether the person is male or female.

M F

13. Are you currently pregnant?

[ ] Yes READ Ineligible Due to Pregnancy Script

[ ] No

(Ineligible Due to Pregnancy script)

I’m sorry but we cannot include anyone who is pregnant in the study. Thank you for taking the time to talk with me today.

14. Have you breastfed a child in the past 6 months?

[ ] Yes READ Ineligible Due to Breastfeeding script

[ ] No

(Ineligible Due to Breastfeeding script)

I’m sorry but we cannot include anyone who has breastfed a child in the past 6 months in our study. Thank you for taking the time to talk to me today.

If participant is eligible for the study go to Eligible Participant script

(Eligible participant script)

Great! You are eligible to take part in this study. Let’s talk about scheduling an appointment for you.

Your appointment will take about two hours. When you come to the clinic, you will be asked some questions to help us find out how you might come into contact with chemicals. We’ll ask you questions like where you live, your activities, and food you eat. You will receive a $25 gift card as a thank you for answering these questions. Then we will get your blood and urine samples. After you have given your samples, you will receive another $50 gift card as a thank you.

15. Do you still want to be part of this study?

[ ] Yes

[ ] No

If NO That’s fine. Thank you for taking the time to talk with me today.

16. If YES Great! Let’s take a look at the available times to find out what works for you. Are there days or times that are better for you?

[ ] Yes

[ ] No

If YES,

Best days ___________________________________________________

Best times ___________________________________________________

17. You could come in at (time/location). Does that work for you?

[ ] Yes

[ ] No If NO, propose another time/location

RECORD Appointment

Date Time Location

______________ _______________ ____________________________

18. Do you have a way to get to (location) for your appointment?

[ ] Yes

[ ] No If NO, offer transportation assistance

Closing script Thank you very much for agreeing to be part of this study. I will mail some information to you including an appointment reminder, a map, and a consent form. We will also call you a few days before to remind you of your appointment.

Please read the consent form before you come to your appointment. Don’t sign the form until you come in for your appointment.

I will include our phone number in the mailing in case you have questions or need to change your appointment. Do you have any questions that I can answer now?

Okay, we’ll see you on (date/time) at (location). Thanks again for taking the time to talk with me today.