Biometric Screener in-person

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Adult Biometric Measures Recruitment Screener (In Person)

Public reporting burden of this collection of information is estimated to average 2 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 D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)

“Thank you for agreeing to participate in the Biometric Study.”

“I am (NAME) with RTI International and we are conducting this study with funding from the U.S. Centers for Disease Control and Prevention, otherwise known as the CDC. In this study we are interested in health-related information about adults. You previously participated in the Adult Targeted Surveillance Survey and agreed to complete this in home survey and examination.”

“This study will involve answering a survey about your health status as well as an examination to collect physical measurements and saliva. First, I will ask you some questions about any recent weight loss/gain or recent illness or medical diagnosis that could affect the physical measurements that I’ll be taking. We will also ask about recent meals, how long ago you smoked tobacco and how much you smoke, if at all, whether you are exposed to tobacco smoke, as well as whether you have had any dental work recently. I will then measure your height, weight, waist circumference, blood pressure and pulse, and obtain a saliva sample to see if you have been exposed to second hand tobacco smoke.”

“Completion of the survey and examination will take you about 30 minutes. At the end of the examination you will be given $40.00 in cash for your participation. Please keep in mind that partial completion of the survey and/or examination will result in partial payment.”

[INSERT ADDENDUM SCRIPT HERE, IF APPLICABLE]

“Do you have any questions?”

“Great. Before we get started here is a copy of the informed consent form. This form explains what you’re being asked to do and the risks and benefits of participating in this study. Please read over this document carefully or I can read the document to you. If you have any questions or don’t understand everything, please don’t hesitate to ask me. Once you have read and understand the consent form, I’ll ask you to sign it. By signing this form, you are acknowledging that you agree to participate in the study. I will give you a copy of the consent form to keep for your records.”

Addendum to Youth and Adult Biometric Study:

Adult Biometric Measures Recruitment Screener (In Person)

[if selected to participate and agreed to accelerometry substudy]: After we take those measurements, we will give you an accelerometer to wear around your waist to measure your physical activity and sedentary behavior for the next 7 days. We will also leave you instructions on how to use and care for the accelerometer. We will also call you 3-4 days after this visit to see if you are having any problems with the accelerometer, and to answer any questions you may have regarding its use.”

[if selected to participate and agreed to accelerometry substudy]: At the end of the accelerometer portion of the study, you will be given a $20.00 gift card for your participation.”

When we look at the data you provide, if we find that we do not have at least 5 days of complete data, we will ask you to wear the accelerometer for another 7 days. You may refuse to wear the accelerometer again if you choose.