Screener

Attachment 3 – Telephone Screener OMB #0920-0222; Expiration Date: 06/30/2015

The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Public reporting burden for this collection of information is estimated to average 5 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 Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0222).

Sample screening script for respondent contact by QDRL Recruiter/QDRL Staff for

Cognitive testing of UNICEF/Washington Group School Environment Questions recruited through newspaper advertisement/flyer

Dial respondent’s telephone number [hereafter referred to as R] as indicated on audio recording.

 Note: Speak only to R. If the number is answered by an answering machine, call back at another time.

QDRL Recruiter/QDRL Staff: Good morning/afternoon, may I speak to (name)?

 If R is not available or not at home, say, “Thank you” and try again at another time.

If the person who answered the phone (NOT R) asks, “Who is calling?” or “What’s this about?” say, “I am returning their call to me. I’ll try to reach them at another time.

 If R has been successfully contacted, continue...

...Hello, my name is [QDRL Recruiter/QDRL Staff ‘s name. I am calling from the National Center for Health Statistics. You may remember that you responded to the advertisement we placed in the [name of newspaper] on [date] or flyer looking for adults aged 18 and over with children living in the household aged 5 to 17 years who may have difficulties in the following areas: seeing, hearing, walking, learning, behavior, depression or anxiety.

 Wait for acknowledgment, such as, “Oh, yes, I remember.”

...In order to determine if you are eligible for our study, I’ll need a few minutes of your time to ask some background questions. Answering these questions is completely voluntary. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent. Is this a good time to ask the questions or should I call back later?

 If not a good time to talk, schedule a time to call back.

 If good time to talk, continue...

1. Where did you see our advertisement?

___________________________________________________

2. How old are you? [If under age 18, go to exit script 1]

________________

3. Are you a parent or guardian of a child living in your household who is between the ages of 5 and 17?

 Yes

 No (Go to exit script 2)

3. What are their ages?

______________

3. Are you the parent or guardian who is most knowledgeable about the physical, emotional, and mental health, and well-being of your [fill] year old?

Yes

 No (Go to exit script 2)

3. Does your child have difficulty in any of the following areas? [If none, go to exit script 2]

a. Seeing – Yes/No If yes, please explain.

b. Hearing – Yes/No If yes, please explain.

c. Walking – Yes/No If yes, please explain.

d. Learning – Yes/No If yes, please explain.

e. Behavior – Yes/No If yes, please explain.

f. Depression or anxiety – Yes/No If yes, please explain

3. How many years of education do you have?

9 or less 10 11 12 13 14 15 16 17 18 19

3. Are you Spanish, Hispanic or Latino?

 Yes

 No

3. What race or races do you consider yourself to be? You may indicate more than one race.

 White

 Black or African American

 Asian

 American Indian or Alaska Native

 Native Hawaiian or Other Pacific Islander

[If individual has not met any of the eligibility requirements go to exit script 2].

[If the recruitment needs for certain groups have been achieved, go to exit script 3].

Entry Script:

...Based on your answers to the questions so far, we would like you to take part in our study. For this study we’d like you to come here to the National Center for Health Statistics in Hyattsville, MD/mutual location. An interviewer will ask you questions about your child’s school and attitudes you may have about education. Then the interviewer will ask you to explain what you were thinking as you answered the questions. The interviewer will also ask you about your opinions of the questions. Your answers will help us find out if the survey questions will be easy for other people to answer. Everything you say will be kept private. With your permission, we would like to record your interview. The recording is a record of what we asked and what you said about the questions. Do you give permission to have your interview video recorded? Yes/No. [If no, ask if for permission to audio record]. Do you give permission to have your interview audio recorded? Yes/No. [If no, go to exit script 4. At a minimum audio recording is essential for this project].

Do you have any questions at this point? Pause to answer questions. If (not/you have no other questions), then let’s get you on the schedule, ok? We will be interviewing (Day, Month/Date) through (Day, Month/Date) from 8 a.m. to 6 p.m. Looking at your schedule, when would you be available to participate? Schedule. [If date/times not available go to exit script 5.]

A reminder call will be made to you a few days in advance. Should you have any questions or need to change your appointment, please feel free to contact me [name] at [phone number]. Thank you for responding to our ad, and I look forward to seeing you here at (DATE/TIME) Get respondent to cite date & time if possible.

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Exit script 1: I’m sorry, you have to be over the age of 18 to take part in this study and therefore we won’t be able to use you at this time. However, I would like to put your name and telephone number you gave me into our database so that I can contact you about other studies coming up in the future. Is that OK? If yes, record name & telephone number. If no: OK, thank you for your time. Your name and telephone number will not be added to our database.

Exit script2: I’m sorry, you have not met one of the eligibility requirements for this particular study. However, I would like to put your name and the information you gave me into our database so that I can contact you about other studies coming up in the future. Is that ok? If yes, record name & number. If no: OK, thank you for your time.

Exit script 3: Based upon your answers, it seems that we may already have a number of volunteers with very similar answers to yours. At this point we need to talk with people with some different characteristics. However, if we have cancellations or other slots open up, I may wish to call you back. Would it be okay if I kept your name, telephone number, and the information you provided in response to the eligibility questions until the end of this study? If yes, make notation. If no, Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.

Exit script 4: I’m sorry, willingness to be audio recorded is required in order to take part in this study and therefore we won’t be able to use you at this time. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.

Exit script 5: I see...ok, we were hoping to complete this particular study between (Month/Date) and (Month/Date), so it looks like we won’t be able to schedule you at this time. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.

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