CHATS Attachment K_revised_02272012

ATTACHMENT K

Eligibility Screener

Form Approved:

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

Feasibility Phase

Baseline Screener for Eligibility

GENERAL NOTES: ENTRIES OF DK AND REF SHOULD FOLLOW THE “NO” PATH, UNLESS OTHERWISE INDICATED.

FOR TESTING, CREATE PRELIMINARY QUESTIONS TO SIMULATE 1) SAMPLE PRELOAD FOR EXPOSED/UNEXPOSED AND 2) CMS CASELOAD STATUS WHETHER WE HAVE MET OUR QUOTA FOR OWNERS vs. RENTERS.

DUMMY1. TESTER: DO YOU WISH TO TEST A SCENARIO FOR A SAMPLE MEMBER WHO WAS EXPOSED TO A FEMA TRAILER?

1 YES, EXPOSED

2 NO, UNEXPOSED

NODK

NOREF

WE DO NOT NEED TO RECORD HISTORICAL ENTRIES IN SCR1-SCR2a, SO THERE IS NO LIMIT ON NUMBER OF TIMES USER GOES BETWEEN SCR2a=1 AND SCR1=2. IN PRACTICE IT WILL LIKELY BE 3 TIMES OR FEWER.

SCR1. Hello, my name is [INTERVIEWER NAME] from RTI International in North Carolina. We are in your neighborhood conducting a study of health in families following Hurricanes Katrina and Rita. You should have gotten a letter explaining the study. INTERVIEWER: SHOW LETTER IF NEEDED. First let me verify: Do you live here?

1 YES

2. NO

DK/REF

SCR2. [IF SCR1=YES] Are you 18 or older?

1 YES

2 NO

DK/REF

Public reporting burden of this collection of information is estimated to average X 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

SCR2a. [IF SCR2=NO/DK/REF OR SCR1=NO] I need to speak with someone who is 18 or older and lives here. May I speak with someone who can help me?

1 YES, PERSON IS COMING TO TALK NOW

2 YES, BUT NEED TO SCHEDULE ANOTHER TIME

3 NO, NO ONE LIVING HERE IS 18 OR OLDER

NODK

NOREF

PROGRAMMER: IF SCR2a=1 THEN SKIP BACK TO SCR1. IF SCR2a=2 THEN SEND USER TO SCR23 FOR SCHEDULING. IF SCR2a=3 THEN SKIP TO SCR29 VERIFICATION. WE DO NOT NEED TO RECORD HISTORICAL ENTRIES IN SCR1-SCR2a, SO THERE IS NO LIMIT ON NUMBER OF TIMES USER GOES BETWEEN SCR2a=1 AND SCR1=2. IN PRACTICE IT WILL LIKELY BE 3 TIMES OR FEWER.

SCR3. I have some questions about the people living here that take 5 to 10 minutes to complete. These screening questions will determine whether anyone is eligible for a study about children’s health in the Gulf Coast region. Households that are found to be eligible have the chance to participate in this important research and receive a token of appreciation for time and effort of up to $125 or $135 depending on the age of the people who live here and your decision to participate. Any information that you tell me will be kept confidential. May I ask you the screening questions now to learn whether anyone living here is eligible?

1 YES

2 NO

PROGRAMMER: IF SCR3=NO, THEN SKIP TO SCR24 REFUSAL

SCR4. Can you verify this address is [PRELOADED ADDRESS]?

1 YES

2 NO

DK/REF

PROGRAMMER: IF SCR4=NO, THEN SKIP TO SCR28b. IF UNEXPOSED AND SCR4=YES THEN SKIP TO SCR7

SCR5. [IF EXPOSED ASK: SCR5 THROUGH SCR6a] Can you verify that [PRELOADED NAME] lives here?

1 YES

2 NO

NODK

NOREF

SCR5a. [IF SCR5=NO] Do you know where [PRELOADED NAME] may have moved?

1 YES

2 NO

NODK

NOREF

SCR5b. [IF SCR5a=YES] Do you have a current address for [PRELOADED NAME]?

1 YES

2 NO

NODK

NOREF

SCR5c. [IF SCR5b =YES] ENTER current address for [PRELOADED NAME]

<STREET>________ [ALLOW 70 CHARACTERS]

<APT>________ [ALLOW 10 CHARACTERS]

<CITY>________ [ALLOW 30 CHARACTERS]

<STATE>________ [ALLOW 2 CHARACTERS – USE STATE LOOK-UP IF POSSIBLE]

SCR5d. [IF SCR5a=YES] Do you have a current phone number for [PRELOADED NAME]?

<PHONE> ________ [ALLOW 10 CHARACTERS]

PROGRAMMER: IF SCR5=NO THEN ASK SCR5a, SCR5b AND SKIP TO SCR29 VERIFICATION

SCR6. [IF SCR5=YES] Did any child age 3 to 15 who is living here now ever live in a FEMA-supplied trailer for at least 2 months?

1 YES

2 NO

DK/REF

PROGRAMMER: IF SCR6=NO, SKIP TO SCR29 VERIFICATION

SCR6a. [IF SCR6=YES] In all, how many children here lived in a FEMA trailer for at least 2 months?

______ [range 0-10]

DK/REF

PROGRAMMER: IF SCR6a=0 OR DK OR REF, SKIP TO SCR29 VERIFICATION

SCR7. [IF UNEXPOSED] Is there at least one child age 3 to 15 living here now?

1 YES

2 NO

DK/REF

PROGRAMMER: IF SCR7=NO, DK OR REF THEN SKIP TO SCR29 VERIFICATION.

SCR7a. [IF SCR7=YES] How many children age 3 to 15 live here now?

_____ (range 0-10]

DK/REF

PROGRAMMER: IF SCR7a=0, SKIP TO SCR29 VERIFICATION

SCR8. [IF EXPOSED AND SCR6a>1 OR UNEXPOSED AND SCR7a>1] One of the children may be eligible for a study of children’s health following Hurricanes Katrina and Rita. Can you tell me the first name or nickname for each child, and his or her birth date?

Let us start with the oldest child [IF EXPOSED: who lived in a FEMA trailer for at least 2 months] and continue with the next oldest child until we reach the youngest.

LOOP STARTS

SCR8a. What is the oldest/[the next] child’s name or nickname?

Note: [the next] is used starting with the second loop

<NAME>__________ [ALLOW 20 CHARACTERS]

DK/REF

SCR8b. [IF EXPOSED AND SCR6a>1 OR UNEXPOSED AND SCR7a>1] Can you tell me [SCR8a]’s birth date?

MM/DD/YYYY

DK-REF/DK-REF/DK-REF

LOOP ENDS

PROGRAMMER: IF EXPOSED, RECORD BIRTH DATE AND NAME IN SCR8 AND SCR8A FOR SCR6a TIMES (ONCE FOR EACH CHILD REPORTED IN SCR6a). IF UNEXPOSED, RECORD BIRTH DATE AND NAME IN SCR8 AND SCR8a FOR SCR7a TIMES (ONCE FOR EACH CHILD REPORTED IN SCR7a)

SCR9. [IF EXPOSED AND SCR6a=1, OR IF UNEXPOSED AND SCR7a=1] That child may be eligible for a study of children’s health following Hurricanes Katrina and Rita. Can you tell me his or her first name or nickname?

<NAME>____________ [ALLOW 20 CHARACTERS]

DK/REF

SCR9a. [IF EXPOSED AND SCR6a=1, OR IF UNEXPOSED AND SCR7a=1] Can you tell me [FILL: SCR9]’s birth date?

MM/DD/YYYY

DK-REF/DK-REF/DK-REF

PROGRAMMER: MAKE INITIAL SELECTION RANDOMLY (DO NOT ALWAYS SELECT “FIRST,” “MIDDLE,” “LAST,” OR “NEXT BIRTHDAY”). CHILD’S NAME OR INITIALS AND BIRTH DATE FROM SCR8 OR SCR9 WILL FILL IN SUBSEQUENT QUESTIONS. ONLY A CHILD WHO IS AGE 3 to 15 AS OF JUNE 1, 2011 IS ELIGIBLE FOR SELECTION. IF NO CHILD IS ELIGIBLE, SKIP TO SCR29 VERIFICATION. IF NO CHILD IS SELECTED IT WILL BE DUE TO 1) THE REPORTED BIRTHDAY(S) NOT BEING WITHIN THE ELIGIBLE AGE RANGE OR MISSING DATA SUCH AS DK OR REF IN ONE OF THE DATE FIELDS. IF NO CHILD IS SELECTED THEN SEND USER TO SCR29 VERIFICATION.

INITIALLY, WE WILL RANDOMLY SELECT 1 CHILD PER HOME WITHOUT REGARD TO ANY QUOTAS BY AGE GROUP, BUT WE NEED TO HAVE A MECHANISMBE TO SHUT DOWN RECRUITMENT OF SPECIFIC AGE GROUPS TOWARD THE END OF THE BASELINE DATA COLLECTION IF WE HAVE TOO MANY OF ONE AGE GROUP. THE SHUT-DOWN OF THE “ALL” AND 1 OF THE OTHER 2 GROUPS WILL HAPPEN ONE TIME TOWARD THE END OF DATA COLLECTION IF IT NEEDS TO HAPPEN AT ALL. THE FOLLOWING ARE SPECS FOR THE SELECTION:

Step 1 – As children are enumerated in the loop, generate a random number between 0-99 and store it in the loop in a hidden question. 

Step 2 – Create three working variables.  

• Lowest_Random – defined as the lowest random number created so far while looping through the collection of child names and ages.

• SelectedName – The name of the child associated with the lowest random number created while looping through the collection of child names and ages.

• SelectedAge – The age of the child associated with the lowest random number created while looping through the collection of child names and ages.

Step 3 – If a child is under 3 or over 15, set the “random” number through code to 100.  That way, they never have the lowest number and are never selected.

Step 4 – If an age group has been “turned off”, set the “random” number through code to 100 for children in that age group.  That way they cannot be selected anymore.  This would probably require an update to the program to implement but it is a onetime update.

Step 5 – For the first child that is between 3 and 15, set Lowest_Random to that child’s random number and set SelectedName to the child’s name and set SelectedAge to that child’s age.

Step 6 – Each time through the loop, compare the new child’s random number to Lowest_Random.  If the new random number is lower than Lowest_Random, set Lowest_Random equal to the new number, SelectedName equal to the new child’s name, and SelectedAge equal to the new child’s age.

Step 7 – When rostering the children is complete, SelectedName would have the name of the selected child in it.

SCR10. [IF EXPOSED] My next questions are about [CHILD] who was born on [MM/DD/YYYY]. If your family stayed in more than one FEMA trailer, think of the one where [CHILD] stayed the longest. In a typical week, how many days did [CHILD] sleep in the trailer?

_____ [range 0-7]

DK/REF

SCR11. [IF EXPOSED] Was that FEMA trailer located on private land or in a trailer park?

1 Private property

2 Trailer park

3 BOTH (e.g., MOVED)

4 NEITHER

DK/REF

SCR12. [IF UNEXPOSED] My next questions are about [CHILD]. Did [CHILD] ever live in a FEMA trailer for at least 2 months?

1 YES

2 NO

DK/REF

PROGRAMMER: IF SCR12=YES THEN INELIGIBLE, SKIP TO SCR29 VERIFICATION

SCR13. [IF UNEXPOSED] Has [CHILD] lived in the Gulf Coast region most of his/her life?

1 YES

2 NO

DK/REF

SCR14. [IF SCR13=NO] Has [CHILD] lived in the Gulf Coast region for the past three years?

1 YES

2 NO

DK/REF

PROGRAMMER: IF SCR14=NO, DK, REF THEN INELIGIBLE, SKIP TO SCR29 VERIFICATION

SCR15. [IF UNEXPOSED] [IF SCR13=1] Did the mother of [CHILD] ever live in a FEMA trailer while she was pregnant with [CHILD]?

1 YES

2 NO

DK/REF

PROGRAMMER: IF SCR15=YES THEN INELIGIBLE, SKIP TO SCR29 VERIFICATION

SCR16. Does a parent or guardian over the age of 18 live with [CHILD] in this household?

1 YES

2 NO

DK/REF

PROGRAMMER: IF SCR16=NO, SKIP TO SCR29 VERIFICATION

SCR17. Does the parent or guardian speak one of these languages: English, Spanish, or Vietnamese?

1 YES

2 NO

DK/REF

PROGRAMMER: IF SCR17=NO, SKIP TO SCR29 VERIFICATION

SCR18. Does the head of this household own or rent this home?

1 OWN

2 RENT

DK/REF

SCR19. Thank you. It turns out that [CHILD] is eligible for our study of children’s health following Hurricanes Katrina and Rita. I need to speak with [CHILD]’s parent or guardian. Would that be you?

1 YES

2 NO

NODK

NOREF

SCR20. [IF SCR19=YES] I’d like to explain more about this study and how you may be able to help us. If this is a good time, we could get started now. I have some information for you about the study and I will need a place to set up a laptop computer. May we begin now?

1. YES

2 NOT NOW, BUT LATER

3 NO, REFUSAL TO INTERVIEW

NODK

NOREF

PROGRAMMER: IF SCR20=1 THEN SKIP TO SCRFINISH AND CODE AS ELIGIBLE, READY-FOR-CONSENT. IF SCR20=2 THEN SKIP TO SCR23 SCHEDULER. IF SCR20=3, SKIP TO SCR24 REFUSAL.

SCR21. [IF SCR19=NO] May I speak with [CHILD]’s parent or guardian?

1 YES

2 NO

NODK

NOREF

PROGRAMMER: IF SCR21=NO THEN SKIP TO SCR24 REFUSAL

SCR22. [IF SCR21=YES] [ONCE PARENT/GUARDIAN IS AVAILABLE] Hello, my name is [INTERVIEWER NAME] from RTI International in North Carolina. We are in your neighborhood conducting a study of health in families following the Katrina and Rita Hurricanes. Based on answers to the screening questions, your child, [CHILD] has been selected for the interview. I’d like to explain the study and how you may be able to help us. If this is a good time, we could get started. I have some information for you about the study and I will need a place to set up a laptop computer. May we begin now?

1 YES

2 NOT NOW, BUT LATER

3 NO, REFUSAL TO INTERVIEW

NODK

NOREF

PROGRAMMER: IF SCR22=1 THEN SKIP TO SCRFINISH AND CODE AS ELIGIBLE, READY-FOR-CONSENT. IF SCR22=3, SKIP TO SCR24 REFUSAL.

SCR23. [IF SCR2a=2 OR SCR20=2 OR SCR21=2 OR SCR22=2] Let me schedule a convenient time to come back. First what would be a good date?

ENTER MONTH AND DAY HERE; ENTER TIME ON THE NEXT THREE SCREENS.

MONTH

DK/REF

DAY

DK/REF

SCR23a. [IF SCR2a=2 OR SCR20=2 OR SCR21=2 OR SCR22=2] (Let me schedule a convenient time to come back.) What would be a good time on [FILL SCR23 DATE]?

ENTER HOUR HERE; ENTER MINUTES ON NEXT SCREEN.

HOUR

DK/REF

SCR23b. [IF SCR2a=2 OR SCR20=2 OR SCR21=2 OR SCR22=2] (Let me schedule a convenient time to come back. What would be a good time on [FILL SCR23 DATE])?

ENTER MINUTES HERE.

DK/REF

SCR23c. [IF SCR2a=2 OR SCR20=2 OR SCR21=2 OR SCR22=2]

ENTER AM OR PM

DK/REF

SCR23d. [IF SCR2a=2 OR SCR20=2 OR SCR21=2 OR SCR22=2]. Thank you for setting an appointment for the CHATS interview. I will return on [FILL SCR23 MONTH] [FILL SCR23 DAY] at [FILL SCR23a HOUR]:[FILL SCR23b MINUTE] [FILL SCR23c AM OR PM].

PROGRAMMER: UPON COMPLETING SCR23a-d, SKIP TO SCRFINISH

SCR24. [IF SCR3=NO OR SCR20=3 OR SCR22=3] Thank you for your time and consideration. I have just a few more questions if you can spare just a couple more minutes. Can you tell me more about your reasons for not participating in this study?

___________________ [ALLOW 100 CHARACTERS]

DK/REF

SCR25. [IF SCR3=NO OR SCR20=3 OR SCR22=3] Are you part of a lawsuit that is related to Hurricane Katrina or Rita?

1 YES

2 NO

DK/REF

SCR26. [IF SCR25=NO] Are you considering joining a lawsuit that is related to Hurricane Katrina or Rita?

1. YES

2. NO

DK/REF

SCR27. [IF (SCR3=NO OR SCR20=3 OR SCR22=3) AND IF EXPOSED SCR6a > 0 OR IF UNEXPOSED SCR7a>0 OR NO CHILD SELECTED] Has a doctor or other health professional ever diagnosed a child in this household with asthma?

1. YES

2 NO

DK/REF

SCR28. [IF (SCR3=NO OR SCR20=3 OR SCR22=3) AND IF EXPOSED SCR6a > 0 OR IF UNEXPOSED SCR7a>0 OR NO CHILD SELECTED] Had you heard about the CHATS study before receiving our letter or talking with me?

1. YES

2 NO

DK/REF

SCR28a. [IF SCR28=1] How did you hear about the CHATS study?

FI: SELECT ALL THAT APPLY

1. A POSTER OR FLYER

2. BY NEWSPAPER, RADIO, OR TELEVISION

3. SOME OTHER WAY

SCR28a_OTH. [IF SCR28a=3] Describe how you heard about the study.

_____________ [ALLOW 50 CHARACTERS]

SCR28b. [IF SCR3=NO OR SCR20=3 OR SCR22=3 OR SCR4=NO] Those are all the questions I have about your household. Thank you for your time

INTERVIEWER: THE REMAINING 3 QUESTIONS ARE TO BE RECORDED BY OBSERVATION.

PRESS NEXT TO CONTINUE

PROGRAMMERS: SKIP TO SCR31

SCR29. [IF SCR2a=3, NO ADULT LIVING HERE OR SCR3=NO OR SCR5=NO OR SCR6=NO OR SCR6a=0 OR SCR9 DID NOT SELECT CHILD OR SCR16=NO OR SCR17=NO SCR20=3 OR SCR22=3; IF UNEXPOSED SCR4=NO OR SCR7=NO OR 7a=0 OR SCR12=YES OR SCR14=NO/DK/REF OR SCR15=YES]. [IF NO SELECTION MADE IN SCR9 THEN FILL: I’m sorry, but the computer did not select a child from this household for the study.] Thank you for taking the time to answer these screening questions. So that my supervisor may check the quality of my work, may I please have your first name?

<FIRST NAME> _________ [ALLOW 20 CHARACTERS]

DK/REF

SCR29a. [IF SCR29 NE REFUSED] (May I have your telephone number?)

<TELEPHONE NUMBER> ___________ (APPLY 3-3-4 FORMAT)

DK/REF

SCR30. Those are all the questions I have. Thank you for your assistance.

INTERVIEWER: THE REMAINING 3 QUESTIONS ARE TO BE RECORDED BY OBSERVATION.

PRESS NEXT TO CONTINUE

SCR31. INTERVIEWER RECORD SCREENING RESPONDENT’S GENDER

1 MALE

2 FEMALE

NODK

NOREF

SCR32. INTERVIEWER RECORD SCREENING RESPONDENT’S RACE. YOU MAY SELECT MORE THAN ONE CATEGORY.

1 White

2 Black or African American

3 Asian

4 Native Hawaiian or Other Pacific Islander

5 American Indian or Alaskan Native

DK

NOREF

SCR32. [ALL SCREENINGS WILL ANSWER] INTERVIEWER RECORD PRIMARY LANGUAGE USED FOR THIS SCREENING.

1 ENGLISH

2 SPANISH

3 VIETNAMESE (THROUGH INTERPRETER]

NODK

NOREF

SCRFINISH. TAP EXIT TO EXIT TO CASE MANAGEMENT SYSTEM (CMS) OR “PREVIOUS” TO GO BACK.

PRESS 1 TO EXIT SCREENER

Eligibility Screener K-19