Screening for focus group sessions

Form Approved

OMB No. XXXX-XXXX

Exp. Date XX/XX/20XX

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

ATTACHMENT 2

Focus Group Screener

Spanish-dominant Latino Men/Women

Caregiver/Patients

Hello, my name is _____, and I’m calling from a local research company. We are conducting a very important research project, and looking for your help. We will absolutely not try to sell you anything, nor ask for a donation, either now or in the future. May I speak to _______. [ASK FOR PERSON ON LIST. DO NOT SPEAK TO ANYONE ELSE IN HOUSEHOLD UNLESS THEIR NAME IS ON THE LIST.]

1. Code, but do not ask:

Male 1 [TERMINATE IF FEMALE GROUP]

Female 2 [TERMINATE IF MALE GROUP]

2. And just so I make sure I have a representative sample, can you tell me if you’re white, black, Latino, Asian, or something else?

White TERMINATE

Black TERMINATE

Latino 1

Asian TERMINATE

Mixed race (vol) TERMINATE

Other [please specify: _____] TERMINATE

Don’t know/ref TERMINATE

Updated to reflect the Census data

3. Where did you or most of your family or ancestors come from – [READ IF NECESSARY] Mexico, Puerto Rico, Spain, Cuba, the Dominican Republic, Guatemala, El Salvador, the Caribbean, South America, Central America, or somewhere else?

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx . The time required to complete this information collection is estimated to average 6 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Mexico 1

Puerto Rico 2

Spain 3

Cuba 4

Dominican Republic 5

Guatemala 5

El Salvador 6

South America 7

Central America 8

Somewhere else [please specify: _____] 9

Don’t know/ref TERMINATE

4. Are you the primary caregiver for anyone in your household, including an elderly relative or child?

Yes 1

No 2

Don’t know/ref TERMINATE

5. In the last 12 months, how many times, if any, did you visit a doctor, the emergency room or the hospital for medical care, either for yourself, your child, or for another relative you might care for?

[Record verbatim response] __ __

1 time or less TERMINATE

2-3 times Continue, schedule call back

3 times or more 3

Don’t know/ref TERMINATE

6. How old are you?

18 to 25 years old 1

25 to 34 years old 2

35 to 44 years old 3

45 to 49 years old 4

50 to 59 years old 5

60 to 69 years old 6

70 or older TERMINATE

Don’t know/ref TERMINATE (RECRUIT A MIX OF AGES)

7. Would you say you can carry on a conversation in Spanish, both understanding and speaking, very well, pretty well, just a little, or not at all?

Very well 1

Pretty well 2

Just a little TERMINATE

Not at all TERMINATE

Don’t know/ref TERMINATE

8. Which language do you prefer to speak, English or Spanish?

English TERMINATE

Spanish 2

Don’t know/ref TERMINATE

9. When you speak with your family members, do you speak Spanish, mostly Spanish, both Spanish and English equally, mostly English, or only English?

Spanish only 1

Spanish mostly 2

S panish and English equally 3

English mostly 4 (MAX OF 4)

English only TERMINATE

Don’t know/ref TERMINATE

10. When you watch television is it only in Spanish, more in Spanish than English, in Spanish and English the same amount, more in English than Spanish or only in English?

Spanish only 1

More in Spanish than English 2

In Spanish and English the same amount 3

More in English than Spanish 4

English only TERMINATE

Don’t know/refused TERMINATE

TERMINATE IF Q 7 = 2 AND Q 9 = 3 OR 4

11. Do you currently have any form of health insurance coverage? [IF YES ASK] Is your health insurance paid for primarily by an employer, do you or a family member pay for it personally, or are you covered by a government sponsored health insurance program like Medicare, Medicaid or TriCare?

Yes, employer 1

Yes, personal 2

Yes, combination employer/personal [vol] 3

Yes, Medicare 4

Yes, Medicaid 5

Yes, TriCare 6

No health insurance 7

Don’t know/refused 8

Added next three questions

12. How serious of a problem do you think racial or ethnic discrimination against Latinos is in this country – a very serious problem, serious problem, a somewhat serious problem, not too serious, or not at all serious?

Very serious 1

Serious 2

Somewhat serious 3

Not too serious 4

Not at all serious 5

Don’t know/refused 6

13. Do you think Latinos who live in your community experience racial or ethnic discrimination, or not? [IF YES ASK] Do you think it happens often, occasionally or rarely?

Often 1

Occasionally 2

Rarely 3

No 4

Don’t know/refused 5

14. Have you ever personally experienced any racial or ethnic discrimination?

Yes 1

No 2

Don’t know/refused 3

TERMINATE IF Q 12 = 4 OR 5 AND Q 14 = 2

TERMINATE IF Q 12 = 6 AND Q 14 = 3

15. What is the highest level of education you’ve had the opportunity to complete?

Less than HS 1

HS graduate 2

Some college 3

College graduate 4

Graduate school/post-grad 5

Don’t know/refused 6

16. Which of the following comes closest to your family income before taxes?

Less than 20 thousand dollars 1

Between 20 and 30 thousand dollars 2

Between 30 and 40 thousand dollars 3

Between 40 and 50 thousand dollars 4

Between 50 and 75 thousand dollars 5

Between 75 and 100 thousand dollars 6

Over 100 thousand dollars 7

Don’t know/refused 8

17. What phrase best described your current marital status?

Single 1

Unmarried but living with a partner 2

Married 3

Separated 4

Divorced 5

Widowed 6

Don’t know/refused 7

18. What is your current occupation?

__________________________________________________________________________

Based on the information you told me, I would like to invite you to discuss issues facing people in this area and around the country. The interviews will be held on (DATE) and will last about 2 hours. We would be pleased to pay you ($75) for your time, and food will be served. Can we count on your participation?

5