Screener

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XX

Attachment 4: Screener for the Community Telephone Interview

CPPW National Prevention Media Initiative Evaluation

Public reporting burden of this collection of information is estimated to average 1 minute 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

I. GREETING AND SCREENER

Hello, my name is _______________. My company is conducting a telephone survey on behalf of the US Centers for Disease Control and Prevention – sometimes known as the CDC. We are surveying adults across the country about several issues. We are NOT seeking contributions and we are NOT selling anything.

1. May I speak with the adult who is most responsible for making decisions about health and wellness in the household? (Do not read response options.)

( ) 1 YES Continue [if the call is given to another person, start from the beginning]

( ) 2 NO, NOT INTERESTED Thank and terminate

( ) 3 NO, NOT A GOOD TIME Ask and record information below

“Could, I could set up another time for this call?”

DAY/DATE: ____________ TIME: _____________

( ) 9 REFUSED Thank and terminate

[If YES, continue.]

We are trying to speak with a wide variety of people about issues related to health and wellness in your community. Before we begin, I’d like to learn a little about you.

2. In what year were you born? (Do not read response options.)

__________ [RECORD YEAR OF BIRTH] Continue if respondent was born in 1987 or earlier.

( ) 8 Don’t Know/Not Sure Thank and terminate

( ) 9 Refused Thank and terminate

3. What is the zip code at the address where you live?

Zip: _________________________________ [Record and verify using list.]

4. Do you consider yourself to be …? [Read responses 1 & 2]

( ) 1 Hispanic or Latino

( ) 2 Not Hispanic or Latino

( ) 3 Don’t Know/Not Sure (DO NOT READ)

( ) 4 Refused (DO NOT READ) Thank and terminate

[Refer to sampling frame]

5. Do you consider yourself to be…? [Read responses 1-5 and allow respondent to select one or more]

( ) 1 White/Caucasian

( ) 2 Black or African-American

( ) 3 American Indian or Alaska Native

( ) 4 Native Hawaiian or Other Pacific Islander

( ) 5 Asian

( ) 8 Don’t Know/Not Sure (DO NOT READ)

( ) 9 Refused (DO NOT READ) Thank and terminate

[Refer to sampling frame]

6. Are there any children living in your household ages 6 to 15?

( ) 1 Yes

( ) 2 No

( ) 9 Refused (DO NOT READ) Thank and terminate

[Refer to sampling frame]

Please use the following termination language if the participant is not eligible: “Thank you very much for your time. I don’t have any further questions for you today.”

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