Verification for Screener

ATTACHMENT P

Verification Questionnaire for Screener

Form Approved:

OMB No. 0920-xxxx

Exp. Date __xx/xx/2012

VERIFICATION QUESTIONNAIRE FOR SCREENER

General Information:

All skips or routing instructions to be programmed are noted next to response in brackets [ ]

Gender = Male/Female

All fills are designated by italics text in parents

(Child Name)

(Mom Name)

(address)

(FI Pronoun): he/she based on FI’s gender

(FI Description): age, gender, height, race

(Screening Date) fill: Date of final Screening Code

Screening Information:

Preload variables from screener:

CaseID

Phone number (designates home or work phone)

Address

Notes to Verification Caller [Additional data from hand-held]

First Name

Screening Date (date of final Screening code)

Final Ineligible Screening Code

Exposure Group:

NON EXPOSED (NEG)

EXPOSED (EG)

Public reporting burden of this collection of information is estimated to average 2 minutes per participant, 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

Screening Script:

>INTRO<

May I speak to (first name)?

<1> SPEAKING TO TARGET RESPONDENT [SINTRO1]

<2> RESPONDENT AVAILABLE (NOT SPEAKING TO TARGET] [if cell number, go to

Cell_Res1, else SINTRO1]

<3> RESPONDENT UNAVAILABLE [CALLBACK]

<4> RESPONDENT UNKNOWN [UNAVAILB]

<5> RESPONDENT KNOWN, BUT WILL NEVER BE AVAILABLE [UNAVAILB]

>UNAVAILB<

OK, perhaps you can help me. (My name is ____________. I am calling from RTI International regarding the Children’s Health after the Storms study sponsored by the Centers for Disease Control and Prevention (CDC).

Our records indicate that (first name) was contacted concerning (address).

This call is to verify the quality of our interviewer’s performance. It will take less than two minutes of your time. For training and quality assurance purposes, this call may be monitored.

Is this the correct phone number for (address)?

(This is a scientific research study and the quality of data is essential. We monitor our interviewer’s work in several ways. One very important check is to call some of the residences that were contacted to ensure the interviewer followed proper procedures and behaved professionally.)

<1> YES [B1PROXY]

<2> NO [DONEB]

<F4> REFUSE [B1PROXY]

>B1PROXY<

Did you speak to our interviewer?

<1> YES [A1]

<2> NO [B1A]

<F4> REFUSE [B1A]

>Cell_Res1<

Hello, my name is _______________. I am calling from RTI INTERNATIONAL regarding the Children’s Health after the Storms study sponsored by the Centers for Disease Control and Prevention (CDC).

Are you in a place where you can safely talk on the phone and answer my questions?

INTERVIEWER: IF THE RESPONDENT CANNOT TALK RIGHT NOW, PLEASE GET A GOOD TIME TO CALLBACK; IF THEY SIMPLY HANGUP, SET A RANDOM APPOINTMENT FOR 4 HOURS LATER.

<1> Yes [S1INTRO]

<2> No [END]

<8> Schedule a callback [END]

<9> Other Codes [END]

>SINTRO1<

(Hello, my name is _______________. I am calling from RTI International regarding the Children’s Health after the Storms study sponsored by the Centers for Disease Control and Prevention (CDC).

Our records indicate that you were contacted concerning (address).

This call is to verify the quality of our interviewer’s performance. It will take less than two minutes of your time. For training and quality assurance purposes, this call may be monitored.

(This is a scientific research study and the quality of data is essential. We monitor our interviewer’s work in several ways. One very important check is to call some of the residences that were contacted to ensure the interviewer followed proper procedures and behaved professionally.)

ENTER (1) TO CONTINUE... [A1]

>A1<

Did the interviewer talk with you face-to-face at your home?

<1> YES [IF EXPOSURE GROUP = NEG GO TO NE_NONE BEFORE LOGIC; IF EXPOSURE GROUP = EG GO TO EG_ROSTER]

<2> NO [A2]

>A2<

How did you speak with the interviewer?

<1> VISIT AT HOME [IF EXPOSURE GROUP = NEG GO TO NE_NONE BEFORE LOGIC; IF EXPOSURE GROUP = EG GO TO EG_ROSTER]

<2> FRONT DESK TELEPHONE/INTERCOM [IF EXPOSURE GROUP = NEG GO TO NE_NONE BEFORE LOGIC; IF EXPOSURE GROUP = EG GO TO EG_ROSTER]

<3> TELEPHONE [B1]

<4> BOTH VISIT AT HOME AND TELEPHONE CONTACT [B1]

<5> RESPONDENT WAS NOT CONTACTED BY INTERVIEWER [B1A]

<6> SOME OTHER WAY [A2ELB1]

>A2ELB1<

Please tell me how you were contacted.

ENTER COMMENTS UP TO 150 CHARACTERS.

IF DURING THE COURSE OF ELABORATION, IT BECOMES APPARENT THAT THE CONTACT WAS IN PERSON OR OVER THE PHONE, BACK UP AND RE-CODE B1A. [IF EXPOSURE GROUP = NEG GO TO NE_NONE BEFORE LOGIC; IF EXPOSURE GROUP = EG GO TO EG_ROSTER]

>B1<

When the interviewer called you by telephone, did (FI Pronoun) make an appointment to see you or did (FI Pronoun) complete our survey by telephone asking questions such as how many children live in this household, their ages, primary language and if any of the children lived in a FEMA-supplied trailer after the hurricanes?

<1> MADE APPOINTMENT ONLY [IF EXPOSURE GROUP = NEG GO TO NE_NONE BEFORE LOGIC; IF EXPOSURE GROUP = EG GO TO EG_ROSTER]

<2> COMPLETED SCREENING QUESTIONS [IF EXPOSURE GROUP = NEG GO TO NE_NONE BEFORE LOGIC; IF EXPOSURE GROUP = EG GO TO EG_ROSTER]

<F3> DON’T KNOW [B1A]

<F4> REFUSE [IF EXPOSURE GROUP = NEG GO TO NE_NONE BEFORE LOGIC; IF EXPOSURE GROUP = EG GO TO EG_ROSTER]

>B1A<

Our interviewer is (FI Description), and would have been wearing a white badge with a picture I.D. (FI Pronoun) would have asked questions like how many children live in this household, their ages, primary spoken language, and if any of the children lived in a FEMA-supplied trailer after the hurricanes. Do you remember this person?

<1> YES [A3]

<2> NO [IF EXPOSURE GROUP = NEG GO TO NE_NONE BEFORE LOGIC; IF EXPOSURE GROUP = EG GO TO EG_ROSTER]

>A3<

Did the interviewer talk with you face-to-face at your home?

<1> YES [IF EXPOSURE GROUP = NEG GO TO NE_NONE BEFORE LOGIC; IF EXPOSURE GROUP = EG GO TO EG_ROSTER]

<2> NO [A4]

>A4<

How did you speak with the interviewer?

<1> VISIT AT HOME [IF EXPOSURE GROUP = NEG GO TO NE_NONE BEFORE LOGIC; IF EXPOSURE GROUP = EG GO TO EG_ROSTER]

<2> FRONT DESK TELEPHONE/INTERCOM [IF EXPOSURE GROUP = NEG GO TO NE_NONE BEFORE LOGIC; IF EXPOSURE GROUP = EG GO TO EG_ROSTER]

<3> TELEPHONE [B1B]

<4> BOTH VISIT AT HOME AND TELEPHONE CONTACT [B1B]

<5> RESPONDENT WAS NOT CONTACTED BY INTERVIEWER [DONEB]

<6> SOME OTHER WAY [A4ELB]

>A4ELB<

Please tell me how you were contacted. ENTER COMMENTS UP TO 150 CHARACTERS. IF DURING THE COURSE OF ELABORATION, IT BECOMES APPARENT THAT THE CONTACT WAS IN PERSON OR OVER THE PHONE, BACK UP AND RE-CODE A4.

>B1B<

When the interviewer called you by telephone, did (FI Pronoun) make an appointment to see you or did (FI Pronoun) complete our survey by telephone asking questions such as how many children live in this household, their ages, primary language, and if any of the children lived in a FEMA-supplied trailer after the hurricanes?

<1> MADE APPOINTMENT ONLY

<2> COMPLETED SCREENING QUESTIONS

<F3> DON’T KNOW

<F4> REFUSE

{If Exposure Group = EG skip to EG_ROSTER; else continue}

Before Logic:

{ASK NE_NONE IF EXPOSURE GROUP = NEG and FINAL CODE X (NO CHILDREN 3-15 in home)}

>NE_NONE<

According to our interviewer, there were no children age 3-15 living at (address) on or around (Date of screening). Is this information correct?

<1> YES [NEWTB]

<2> NO [NEWTB]

ASK NE_NONE IF EXPOSURE GROUP = NEG and FINAL CODE XX Study Languages not spoken by children}

>NE_NUMS<

According to our interviewer, none of the children age 3-15 living at (address) on or around (Date of screening) speak English, Spanish or Vietnamese. Is this information correct?

<1> YES [NEWTB]

<2> NO [NEWTB]

{ASK NE_NUMC IF EXPOSURE GROUP = NEG and # children from Q6 in screener not equal 0)

>NE_NUMC<

According to our interviewer, there (fill # of children from screener) age 3-15 living at (address) on or around (Date of screening). Is this information correct?

<1> YES

<2> NO

>NE_ROSTER<

According to our interviewer, the following children age 3-15 were living at (address) on or around (Date of screening):

(Screening Roster Data)

Is this information correct?

TI NOTE: ROSTER AGES DO NOT NEED TO BE EXACT. A DIFFERENCE IN AGE OF BETWEEN 1 & 2 YEARS IS ACCEPTABLE AS CORRECT. CHILDREN WHO WERE AGE 18 OR OLDER ON THE SCREENING DATE SHOULD NOT BE INCLUDED ON ROSTER.

<1> CORRECT ADDRESS, CORRECT INFORMATION

<2> CORRECT ADDRESS, WRONG INFORMATION

<3> WRONG ADDRESS, CORRECT INFORMATION

<4> WRONG ADDRESS, WRONG INFORMATION

<F3> DON’T KNOW

<F4> REFUSE

{Ask NE_C1Sel if Exposure group NEG and Final Code =Y Ineligible Control-Exposed}

>NE_C1Sel<

According to our records, (CHILD NAME) lived in a FEMA-supplied trailer for at least two months following hurricane Katrina or Rita. Is this correct?

<1> YES [NEWTB]

<2> NO [NEWTB]

{Ask NE_Less1 if Exposure group NEG and Final Code =Z Ineligible- Lived in Gulf less than 1 year}

>NE_Less1<

According to our records, (CHILD NAME) has lived in the Gulf Coast region for less than 1 year of (his/her) life. Is this correct?

<1> YES [NEWTB]

<2> NO [NEWTB]

{Ask NE_MOME if Exposure group= NEG and Final Code =YY Ineligible- Mom Exposed}

>NE_MomE<

According to our records, (MOTHER NAME) lived in a FEMA-supplied trailer following hurricane Katrina or Rita. Is this correct?

<1> YES [NEWTB]

<2> NO [NEWTB]

{ASK EG_ROSTER IF EXPOSURE GROUP}

>EG_ROSTER<

According to our interviewer, the following children age 3- 15 were living at (address) on or around (Fill Screening Date):

(Screening Roster Data)

Is this information correct?

TI NOTE: ROSTER AGES DO NOT NEED TO BE EXACT. A DIFFERENCE IN AGE OF BETWEEN 1 & 2 YEARS IS ACCEPTABLE AS CORRECT. CHILDREN WHO WERE AGE 18 OR OLDER ON SCREENING DATE SHOULD NOT BE INCLUDED ON ROSTER.

<1> CORRECT ADDRESS, CORRECT INFORMATION

<2> CORRECT ADDRESS, WRONG INFORMATION

<3> WRONG ADDRESS, CORRECT INFORMATION

<4> WRONG ADDRESS, WRONG INFORMATION

<F3> DON’T KNOW

<F4> REFUSE

{ASK EG_NONE IF EXPOSURE GROUP = EG and Final Code ZZ- ineligible- children and mom not exposed}

>EG_NONE<

According to our interviewer, none of the children age 3-15 living at (address) on or around (Date of screening) lived in a FEMA-supplied trailer for 2 or months following hurricanes Katrina or Rita. Is this information correct?

<1> YES [NEWTB]

<2> NO [NEWTB]

{ASK EG_MNE IF EXPOSURE GROUP = EG and Final Code ZZ- ineligible- children and mom not exposed}

>EG_MNE<

According to our interviewer, none of the mothers of the children age 6 or less living at (address) on or around (Date of screening) lived in a FEMA-supplied trailer while pregnant following hurricanes Katrina or Rita. Is this information correct?

<1> YES [NEWTB]

<2> NO [NEWTB]

{ASK EG_SCNS IF EXPOSURE GROUP = EG and Final Code- Selected Child ineligible- Never Slept in FEMA-supplied Trailer}

>EG_SCNS<

According to our interviewer, (Child NAME) never slept in a FEMA-supplied trailer following hurricanes Katrina or Rita. Is this information correct?

<1> YES [NEWTB]

<2> NO [NEWTB]

{ASK EG_NONES IF EXPOSURE GROUP = EG and FINAL CODE XX Study Languages not spoken by children}

>EG_NONES<

According to our interviewer, none of the children age 3-15 living at (address) on or around (Date of screening) speak English, Spanish or Vietnamese. Is this information correct?

<1> YES [NEWTB]

<2> NO [NEWTB]

>NEWTB<

[IF B1B =2 OR B1IF EXPOSURE GROUP = NEG GO TO NE_NONE BEFORE LOGIC; IF EXPOSURE GROUP = EG GO TO EG_ROSTER = 2, SKIP TO IPRFB]

When the interviewer asked you about children living in your household, did the interviewer enter the information into a small hand-held computer, or did (FI Pronoun) write it down on paper?

<1> ENTERED IN COMPUTER [IPRFB]

<2> WRITTEN ON PAPER [IPRFB]

<F3> DON’T KNOW [IPRFB]

>IPRFB<

Was the interviewer polite and did the interviewer treat you professionally?

<1> YES [DONEB]

<2> NO [ELB1B]

>ELB1B<

Would you please tell me more about that?

ENTER ADDITIONAL COMMENTS UP TO 150 CHARACTERS.ENTER RESPONDENT’S ANSWER VERBATIM. IF NO COMMENTS, ENTER NONE [DONEB]

>DONEB<T

Those are all of the questions I have. Thank you very much for your time. Have a good (evening/day).

ENTER (1) TO CONTINUE AND FINALIZE THE VERIFICATION.

Verification Questionnaire for Screener P-13