Material Testing of Health Hazard Evaluation Program Investigation Reports

Form approved

OMB No. 0920-0940

Expiration date: 06/30/2015

Task B

Appendix A: Testing Session Screener

Introduction: Hello, my name is __________. Thank you for your interest in participating in a discussion session about Health Hazard Evaluation reports.

<insert background and history on the recent HHE conducted at the location>

We’re conducting a study about employee and employer reactions to these reports. Your input is critical in making sure that these reports meet the needs of working people like you.

Your participation will involve two activities. First, we will send you a report to read and then ask you some questions about how the report could be improved. Then, we will invite you to a small group discussion with several other people from your company, which will last 60 to 90 minutes. During the group discussion you will be served light refreshments. At the end of the group discussion, you will be given $75 cash for your participation.

Would you be interested in participating?

• Yes (proceed to next paragraph)

• No (try and convince them how important their opinion is. If cannot be swayed, thank them for their time and end call)

(Q & A if needed) How do I know this is legitimate? Please call Stefanie Brown at NIOSH (513-222-2733) to confirm the sponsor of this discussion group.

I need to ask you a few questions now to make sure that you meet the criteria that NIOSH is looking for.

1. Do you read in the English language?

• No [thank and terminate]

• Yes

2. Are you an employee at <insert company name here>?

• Yes [continue]

• No [thank and terminate]

3. Were you working at <insert location here> when the Health Hazard Evaluation took place in <insert dates of HHE>.

• No [thank and terminate]

• Yes

4. Do you currently supervise another employee?

• No

• Yes

If yes, what is your job title?

• Plant manager/Office manager [thank and terminate]

• President [thank and terminate]

• Health and safety officer [thank and terminate]

• Chief Executive Officer/Chief Financial officer [thank and terminate]

• Other (specify:___________) [continue]

1. Do you consider yourself to be someone who always, sometimes, rarely, or never enjoys speaking in a small group of people?

Always	[continue]
Sometimes	[continue]
Rarely	[hold]
Never	[thank and terminate]

6. Which of the following includes your age?

• 18-29

• 30-39

• 40-49

• 50-59

• 60-69

• 70 and older

7. Are you from a Hispanic, Latino, or Spanish speaking background?

• No

• Yes

8. What race would you classify yourself as?

• Black/African American

• White/Caucasian

• American Indian or Alaska Native

• Asian

• Native Hawaiian or other Pacific Islander

9. Are you:

• Male

• Female

Standard Invitation: As I mentioned before, the discussion session will last 60-90 minutes, light refreshments will be served, and you will receive $75.

The employer testing session will be held on: _________________________________

The employee testing session will be held on: _________________________________

If you wear glasses please be sure to bring them with you.

Please also note that we cannot provide child care and children will not be allowed in the discussion group.

Will you be able to join us?

• Yes (proceed to “address” paragraph at the end of this document)

• No – not interested after all (try and convince them how important their opinion is. If cannot be swayed, thank them for their time and end call)

• No – (thank them for their time and end call)

Contact Info

So that we can send you directions and a letter to confirm your participation, may I please have (or, confirm) your name and address? We will use your name and address only to schedule the discussion group. After your discussion group is completed, we will destroy this personal information.

Name: (VERIFY CORRECT SPELLING)

Address: ____________________________________________________________

City: ___________________ State: ____ Zip: ____________________

Telephone: ______________________

Email: _____________________________

We will call you the day before the discussion group to remind you about the group. Is it ok to call you at this number or is there a better phone number to reach you?

• YES, OK TO CALL THIS NUMBER

• NO, CALL DIFFERENT NUMBER -- > RECORD NUMBER BELOW

NUMBER TO CALL TO REMIND:____________________________

Thank you for agreeing to participate. We look forward to seeing you.

Public reporting burden of this collection of information 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. 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 E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-0260).