Attachment A - Focus Group Screening Questionnaire - rev 01-17-2012 ENGLISH

Site: ______________________________ OMB Control Number # 0584-0524

Date: _____________________________ Expiration Date:04/30/2013

APPENDIX A: Focus Group Screening Questionnaire

OMB BURDEN STATEMENT: 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 0584-0524. The time to complete this information collection is estimated to average 15 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.

USDA/FNS

Focus Group Screening Questionnaire – Mexican American Low-Income Mothers

RESEARCH CONTACT: Leticia Diaz at 202-955-6222 x. 2517

SPECS:

• Four, 120-minute focus groups with low-income Spanish-speaking, Mexican-American mothers of pre-school age children (2-5 years of age and not yet in kindergarten), one group per location in San Antonio, TX and Corpus Christi, TX, one group in Houston, TC; and two, 120-minute focus groups with low-income Spanish-speaking, Mexican-American mothers of elementary school age children (6-10 years of age), one group per location.

• Recruit 14 for 10 to show (seat) at each group.

• Each woman must be in a low-income household (see Q15 and Q16); at least half must participate in one or more nutrition programs, such as WIC, SNAP, etc. (see Q14); and at least half of recruited participants must have a HS education or less. None of the recruited participants should be college graduates or have a higher education degree.

• All respondents must consider themselves of Mexican ethnicity and be fluent in Spanish, meaning that speaking, reading, and writing in Spanish comes naturally to them.

• All respondents must be outgoing, responsive, articulate, willing and able to read and react to written materials, and must be willing to speak openly in a group.

EACH PARTICIPATING COMMUNITY ORGANIZATION WILL SCHEDULE/RECRUIT RESPONDENTS FOR THEIR LOCATIONS AS FOLLOWS:

	GROUP	DATE	TIME (Central Time)	LOCATION
[ ]	Group 1 CFP: Low-income Spanish-speaking, Mexican American mothers of pre-school age children (2-5 yrs. old and not yet in kindergarten)	TBD based on Approval timing	4:00-6:00pm	Houston, TX
[ ]	Group 2 WG; M: Low-income Spanish-speaking, Mexican American mothers of pre-school age children (2-5 yrs. old and not yet in kindergarten)	TBD based on Approval timing	6:30-8:30pm	Houston, TX
[ ]	Group 3 WG; M: Low-income Spanish-speaking, Mexican American mothers of pre-school age children (2-5 yrs. old and not yet in kindergarten)	TBD based on Approval timing	4:00-6:00pm	San Antonio, TX
[ ]	Group 4 M; F/V; WG: Low-income Spanish-speaking, Mexican American mothers of elementary school age children (6-10 yrs.)	TBD based on Approval timing	6:30-8:30pm	San Antonio, TX
[ ]	Group 5 CFP: Low-income Spanish-speaking, Mexican American mothers of pre-school age children (2-5 yrs. old and not yet in kindergarten)	TBD based on Approval timing	4:00-6:00pm	Corpus Christi, TX
[ ]	Group 6 M; F/V; WG: Low-income Spanish-speaking, Mexican American mothers of elementary school age children (6-10 yrs.)	TBD based on Approval timing	6:30-8:30pm	Corpus Christi, TX

[CFP = All Child Feeding Practices Messages and Supporting Content]

[WG = Whole Grain Messages and Supporting Content]

[M = Milk Messages and Supporting Content]

[F/V = Fruit/Vegetable/Availability/Accessibility Messages and Supporting Content]

MODEL INTRODUCTION:

Hello, my name is _____with______. We are conducting a study about nutrition and I would like to ask you a few questions. I’m not trying to sell you anything. We would like to invite a number of women in your area to participate in a focus group to review a series of informational materials related to the nutrition and health of your family. This should only take a few minutes. ONCE HEAD OF HOUSEHOLD ON PHONE, REPEAT INTRODUCTION AND READ OMB STATEMENT (see top of screener).

1. Record Gender—DO NOT ASK UNLESS UNABLE TO TELL.

Female………………………………………	[ ]	Continue
Male ………………………………………..	[ ]	Terminate

2. Do you, or does anyone in your household, work for a radio station, television station, newspaper, market research company, advertising or public relations company?

Yes…………………………………………	[ ]	Terminate
No………………………………………….	[ ]	Continue

3. Are you the mother of any children under age 19, who live in your home?

Yes…………………………………………	[ ]	Continue
No …….…………………………………...	[ ]	Terminate

4. How old are your children? [check all that apply]

Under 2…………………………………….	[ ]	Terminate
2-5 years old.………………………………	[ ]	If one of these is checked, continue.
6-10 years old.……………………………..	[ ]
11 and up…...………………………………	[ ]	Terminate

5. Do you or does anyone in your household work in any of the following industries? [Record each “yes” response.]

	Yes
Healthcare/Medical………………………………	[ ]	Terminate if “YES” to any
Nutrition/Food Service……..……………………	[ ]
Fitness……..……………………………………..	[ ]
Dairy farm/Dairy Council/Food manufacturing…	[ ]
School Food Service…………….…………….…	[ ]
Food/Nutrition Assistance Programs…………….	[ ]

6. Have you ever participated in a focus group or been paid to be part of a discussion group?

Yes……..…………………………………………	[ ]	Continue
No………………………………………………..	[ ]	Skip to Q10

7. How recently did you participate in a focus group?

Less than 6 months ago………………………….	[ ]	Terminate
6 months ago or longer ………………………….	[ ]	Continue

8. Generally speaking, do you consider yourself to be an “expert” in nutrition?

No……………………………………………….	[ ]	Continue
Yes …….…….………………………………….	[ ]	Terminate
Don’t know/Refused............................................	[ ]	Terminate

9. Do you or your child(ren) observe any religious reasons or have any health condition where you have to eat a special diet, cannot eat certain foods (such as milk or grains) or have a diet prescribed by your doctor?

No……………………………………………….	[ ]	Continue
Yes …….…….………………………………….	[ ]	Terminate

10. Are you a vegetarian or vegan?

No……………………………………………….	[ ]	Continue
Yes …….…….………………………………….	[ ]	Terminate

11. Who does most of the grocery shopping or makes the shopping lists/decides what groceries to buy in your household? [DO NOT READ RESPONSES]

You…………………………………………….	[ ]	Continue
Someone else…….…….………………………	[ ]	Terminate

12. Are you or your child participating in any one of the following nutrition programs? [select all that apply]

SNAP or other Food Stamp Programs………...........	[ ]	Record.
Free- or Reduced Price School Lunch/Breakfast …..	[ ]
Women, Infants, and Children Program (WIC)…….	[ ]

[If none selected, continue to Q. 13; if any programs selected, ask Q.13, then continue to Q15]

13. Including yourself, how many people currently live in your household?

__________ [Record answer]

14. What is your total annual household income before taxes¹? [Do not read list]

Less than $20,665…………	1	Record number below
$20,665 - $27,991…………	2	Record number below
$27,992 - $35,317…………	3	Record number below
$35,317 - $42,643…………	4	Record number below
$42,643 - $49,969…………	5	Record number below
$49,967 - $57,295…………	6	Record number below
$57,295 - $64,621…………	7	Record number below
$64,622 - $71,947…………	8	Record number below
More than $71,947………..	[ ]	Terminate
Don’t know/Refused ……...	[ ]	Terminate

Answer to question 13: ____________ Answer to question 14: _______________

Accept respondent if he/she falls into one of the following categories:

a.___ Has 1 person in household (Q13), and answer to Q14 is 1.

b.___ Has 2 people in household (Q13), and answer to Q14 is 1 or 2.

c.___ Has 3 people in household (Q13), and answer to Q14 is 1, 2, or 3

d.___ Has 4 people in household (Q13), and answer to Q14 is 1, 2, 3, or 4

e.___ Has 5 people in household (Q13), and answer to Q14 is 1, 2, 3, 4, or 5.

f.___ Has 6 people in household (Q13), and answer to Q14 is 1, 2, 3, 4, 5, or 6.

g.___ Has 7 people in household (Q13), and answer to Q14 is 1, 2, 3, 4, 5, 6, or 7.

h.___ Has 8+ people in household (Q13), and answer to Q14 is 1, 2, 3, 4, 5, 6, 7, or 8.

[INTERVIEWER, RECORD WHICH CATEGORY RESPONDENT FALLS INTO]

[IF RESPONDENT FALLS OUTSIDE OF CATEGORIES ABOVE, TERMINATE]

15. What is your current age? [Do not read list]

18 and under …………………………………..	[ ]	Terminate
19-40 …….……................................................	[ ]	Record
40-45…….…………………………………….	[ ]	Put on “Holds” list
46+ ……............................................................	[ ]	Terminate

16. Are you of Mexican heritage (participant herself is Mexican or her parents/grandparents are from Mexican origin)?

No……………………………………………..	[ ]	Terminate
Yes …….…….……………………………….	[ ]	Continue

17. What is the highest level of education you have completed? [Do not read list]

High school graduate or less. Record highest grade-level completed.…….............................	[ ]	Recruit Half HS or Less
Some vocational or technical school………………………………..................	[ ]	Recruit a mix
Some college _________ [Number of years]…………………………………...............	[ ]	Record the number of years, and recruit a mix
College graduate, Post graduate education (e.g., Master’s degree, MBA, law degree, PhD)………......................................................	[ ]	Terminate

18. What language do you use to speak to close friends and family?

Only Spanish.…….…………………………..	[ ]	Continue
Mostly Spanish with some words in English…	[ ]	Continue
A mix of English and Spanish………………	[ ]	Accept up to 3
All or mostly English…………………………	[ ]	Terminate

19. How comfortable would you be reading an information pamphlet that is written in Spanish and telling a group what you think about it?

Very comfortable.…….……………………...	[ ]	Continue
Somewhat comfortable………………………	[ ]	Continue
Somewhat uncomfortable…………………...	[ ]	Terminate
Very uncomfortable…………………………	[ ]	Terminate

20. Are you currently employed?

Yes, full-time……………................................	[ ]	Recruit a mix of employed and not employed
Yes, part-time………………………………..	[ ]
No……………………………………………	[ ]

21. Are you:

Married………………………........................	[ ]	Recruit a mix
Single, never married ……………………….	[ ]
Separated/divorced/widowed……………….	[ ]

22. Take a moment and think about your health. What is the biggest concern you have about your health and why? [INTERVIEWER, RECORD RESPONSE]

Recruiter: After recording respondent’s answer, determine whether or not you feel this respondent would be useful in the group. Did she:

[ ] Give full and complete answer?

[ ] Speak clearly, and without long pauses?

[ ] Answer enthusiastically?

[ ] Is fluent in Spanish and can read and comprehend Spanish-language materials.

It is most important that respondent be articulate!! If not, please terminate.

I would like to invite you to participate in a group discussion that will be held at our facility on [DATE] at [TIME]. The group will last approximately 90 minutes. To help cover costs such as transportation to the focus group site and child care, you will receive $75 at the end of the group session. Would you be willing to participate?

Yes……………( ) SCHEDULE No……………..( ) TERMINATE

I will call you to remind you of this appointment. However, if for some reason you are unable to attend, please call me at [COMMUNITY ORGANIZATION CONTANT PHONE NUMBER] so that I can find a replacement for you. Thank You.

[INTERVIEWER, CAPTURE CONTACT INFORMATION]

Respondent’s name: ___________________________________________

Address: ____________________________________________________

Telephone # (Home): __________________ (Work) _________________

Cell _______________________________E-mail _____________________

Recruited by: _________________________________________________

1 WIC Income Eligibility Guidelines (Effective July 1, 2012 to June 30, 2013), as found in , http://www.fns.usda.gov/wic/howtoapply/incomeguidelines12-13.htm

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