Communication Testing for Comprehensive Communication Campaign for HITECH Act

Form Approved

OMB No. 0955-0005

Exp. Date 07/31/2014

ATTACHMENT A

PARTICIPANT SCREENER FOR HIPAA PRIVACY RULE FOCUS GROUP SESSIONS

Referred by (email/organization/etc): _____________________________

Recruiter:_________________________________

Date Recruited: ____________________________

Thank you for calling about the focus groups we are doing. First, let me ask you, how did you hear about this?_________________________ (also fill in above under “referred by”)

I’m going to tell you a little about what we are doing, and then if it sounds interesting to you, I will ask you a few questions to see if you are eligible to participate in the group.

We are working with the U.S. Department of Health and Human Services on a public health campaign. We’re currently recruiting participants for focus groups that will take place the evening of (INSERT DATE) from 6PM to 8PM. Everyone who is selected to participate will receive $75 in cash for their time. Are you available on this day? (If yes, continue, if no, thank them for their time)

Great.

I’ll need to ask you for some personal information in order to determine if you are eligible.

But first, please know that any and all information discussed today is kept completely confidential.

Do I have your permission to proceed?

Yes____

No ____

(If yes, continue, if no, thank them for their time)

Great, let’s get started.

1. Have you or any member of your household ever worked:

For market research company _____

For an advertising agency or public relations firm _____

For the media (TV/radio/newspapers/magazines) _____

As a healthcare professional (as a doctor, nurse, other healthcare professional) _____

For a health insurance provider _____

For a managed care organization or any healthcare provider _____

For a medical practice _____

[IF YES TO ANY >> TERMINATE]

DO NOT RECRUIT ANYONE EVER EMPLOYED IN THE MEDICAL FIELD, IN HEALTHCARE, HEALTH INSURANCE, MARKETING, OR ADVERTISING

2. Are you currently employed?

Yes _____

No _____

3. Are you currently an employee of the federal government?

TERMINATE >> Yes _____

No _____

4. What is your occupation? [If retired or unemployed, indicate and record former occupation]

If married, what is your partner’s occupation?

________________________________________________________

________________________________________________________

[GROUNDS FOR TERMINATION >> CANNOT BE MEDCIAL / HEALTHCARE / HEALTH INSURANCE / PR / OR MARKETING RELATED]

5. What is your gender?

Male____

TERMINATE >> Female____

6. What is your sexual orientation?

Homosexual____

Bisexual____

TERMINATE >>Heterosexual____

TERMINATE >>Other____

7. Please tell me your age.

18-24 _____

25-29 _____

30-39 _____

TERMINATE >> 40-49 _____

TERMINATE >> 50-59 _____

TERMINATE >> 60-69 _____

TERMINATE >> 70 or older _____

8. What is the highest level of education that you completed?

[Recruit a mix]

High School____

Some College____

TERMINATE>> College Graduate____

TERMINATE>> Graduate School____

9. What is your race?

African American/ Black_____

TERMINATE >> Caucasian_____

TERMINATE >> Asian _____

TERMINATE >> Hispanic_____

TERMINATE >>Native American_____

TERMINATE >> Mixed_____

10. Are you HIV positive?

Yes_____

TERMINATE>> No_____

11. How many years have you been diagnosed with HIV?

[Recruit a mix]

Less than 1 year____

2 to 5 years____

TERMINATE >> 6 to 10 years____

TERMINATE >> 11 to 15 years____

TERMINATE >> 16 to 20 years____

TERMINATE >> 21 + years____

12. Have you ever worked or volunteered services at an AIDS service organization?

Terminate>>Yes____

No____

13. In the least 12 months how many times have you been to your Primary Care Physician?

0 visits____

1 to 3 visits____

TERMINATE >> 4 to 6 visits____

TERMINATE >>7 to 10 visits___

TERMINATE >> 11+visits____

14. Have you ever requested access to your medical records from your doctor’s office?

TERMINATE>> Yes____

No____

15. Have you ever attended a focus group discussion or a personal interview for research purposes? By that we mean an informal, round-table discussion or a personal in-depth interview, conducted by a professional moderator, in which you were asked your opinions regarding a product, a service, or advertising?

ASK Follow-Up Questions >> Yes _____

INVITE TO GROUP >> No _____

1. How many of these groups have you attended?

______________________________ [MAX. 2-3 EVER]

2. What was/were the topics discussed?

______________________________[IF HEALTHCARE, TERMINATE]

3. How long ago was the last one of these groups you attended?

______________________________[MUST BE AT LEAST 6 MONTHS AGO]

Congratulations, based on your responses you qualify to participate in the focus group on (INSERT DATE) from 6PM to 8 PM. (Request Contact Information)

Name:_________________________________________________________________

Cell Phone:______________________________________________________________

Email:__________________________________________________________________

The focus group will be held at (INSERT LOCATION). On the day of the focus group we ask that you please arrive 15 minutes early. I will send you an email confirmation with focus group details for your reference and call you to remind you of the focus group 2 days prior.

When I call is it OK to leave a message?______________

Thank you, have a nice day.

Termination Statement:

Unfortunately, you do not meet eligibility requirements for this opportunity. However, we appreciate your interest and willingness to participate. Thank you.

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 0955-0005. The time required to complete this information collection is estimated to average 10 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