Attachment 3D Web Survey Screener (rev08282012)

ATTACHMENT 3D

CMV Web Survey Screener

CMV Screener

DRAFT

3/26/12

Welcome and thank you for agreeing to take part in our survey! Please be assured that all your answers will be kept secure to the extent provided by law and reported in the aggregate only.

1. In which country or region do you currently reside?

[PROGRAMMER: DISPLAY CODES IN ALPHABETICAL ORDER]

[DISPLAY RESPONSES IN TWO COLUMNS GOING DOWN.]

14 Australia

15 Austria

24 Belgium

42 Canada

60 Denmark

76 France

85 Germany

89 Greece

123 Italy

286 Ireland (Republic of Ireland)

168 Netherlands

171 New Zealand

179 Norway

190 Portugal

215 Spain

223 Sweden

224 Switzerland

244 United States of America

266 England

267 Scotland

268 Wales

285 Northern Ireland

996 Other country

2. Are you…?

1. Male

2. Female

3. In what year were you born? Please enter as a four-digit number, e.g., 1963.

|_|_|_|_|

4. In what state or territory do you currently reside?

[ALPHABETIZE CODES IN A DROP DOWN BOX]

5. What is your zip code? Please enter only the first five digits.

|_|_|_|_|_|

6. Do you have a child who is 5 years old or less?

• IF YES → CONTINUE

• IF NO → THANK AND END

7. Are you currently pregnant?

1. 

   TO BE ELIGIBLE, PARTICIPANTS MUST SAY YES TO EITHER Q7 OR Q8

   IF YES → SKIP TO Q5

2. IF NO → CONTINUE

3. Decline to answer → THANK AND END

8. Do you plan to get pregnant within the next
   12 months?

1. YES → CONTINUE

2. NO → THANK AND END

3. Decline to answer → THANK AND END

9. Do you have a child with a disability?

1. IF YES → THANK AND END

2. IF NO → CONTINUE

10. Are you currently or have you ever been a health care provider (e.g., as a nurse, physician or medical assistant)?

1. IF YES → THANK AND END

2. IF NO → CONTINUE

11. What is the highest level of education you have completed?

1. Less than high school

2. High school diploma or GED

3. Technical college/Associates degree

4. Some college

5. College degree

6. Graduate degree

12. Are you of Hispanic or Latino origin?

( ) Yes→ THANK AND END

( ) No

13. How would you describe your race? (Select all that apply)

1. American Indian or Alaska Native → THANK AND END

2. Asian → THANK AND END

3. Black or African American

4. Native Hawaiian or Other Pacific Islander → THANK AND END

5. White

6. Refused → THANK AND END

14. Which of the following income categories best describes your total 2011 household income before taxes?

1. Less than $15K

2. $15K - $24,999

3. $25K - $34,999

4. $35K - $49,999

5. $50K - $74,999

6. $75K - $99,999

7. $100K - $124,999

8. $125K - $149,999

9. $150K to $199,999

10. $200K - $249,999

11. $250K or more

12. Decline to answer

15. In order to test for the presence of the Flash Player, we are presenting a series of numbers in the screen below. It may take a moment for the image to resolve.

What series of numbers is being presented?

[PN: Insert Flash Code as per standards]

1. 23568 → THANK AND END

2. 34678 → THANK AND END

3. 86236 → CONTINUE

4. 87456 → THANK AND END

5. 98125 → THANK AND END

6. 98567 → THANK AND END

7. I am unable to see the series of numbers being presented. → THANK AND END

THANK: Those are all the questions I have for you. Thank you.

QUOTAS
	Caucasian	African American
Number (N)	(n=400)	(n=400)
Education	Mix of education levels	Mix of education levels
Pregnancy status	Mix of pregnant and planning pregnancy (within next 12 months)	Mix of pregnant and planning pregnancy (within next 12 months)