Form Approved
OMB No. 0955-0005
Exp. Date 07/21/2014
Attachment 1: Participant Recruitment Screener for Cognitive Interviews (to be administered by focus group facility)
RESPONDENT'S NAME ______________________________________________________________________________
ADDRESS ____________________________________________ APT. ______ PHONE ( ) __________________
CITY _________________________________ STATE _______________________ ZIP CODE _____________________
RECRUITING INTERVIEWER'S NAME _____________________________________________ DATE _______________
SCREENER
We are conducting a health care related survey and would like to ask you some questions.
Record Gender (Do Not Ask)
Male [ ]
Female [ ]
Into which of the following age groups does your age fall?
Under 18……………………………… [ ]
18 – 24 [ ]
25 – 34…………………………………[ ]
35 – 44 [ ]
45 – 54 [ ]
55 – 64 [ ]
65 or older……………………………..[ ]
Which of the following best describes your current employment status?
Employed Full-Time [ ]
Employed Part-Time [ ]
Homemaker [ ]
Retired [ ]
Unemployed/Looking for work [ ]
Which of the following best describes your total household income?
Below $30,000 [ ]
$30,000 to below $60,000 [ ]
$60,000 to below $90,000 [ ]
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 one hour and thirty 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
What
is the highest level of education you have completed?
Some high school [ ]
High school graduate [ ]
Some college [ ]
College graduate [ ]
Technical/trade school [ ]
Some graduate school [ ]
Graduate Degree [ ]
Are you of Hispanic, Latino, or Spanish origin?
Yes [ ]
No [ ]
Do you identify as African American?
Yes [ ]
No [ ]
J. You are being recruited for an interview where you will be interviewed on a range of social and health topics. This is to help our client finalize a questionnaire for a telephone survey. An interviewer will first ask you the questionnaire items, then will ask you follow-up questions on some of the items. You may be asked about certain terms or phrases used in the questionnaire, or to rephrase some questions in your own words. They will pay you $40 cash in appreciation of your time. Would you be comfortable with all of this?
Yes [ ]
No [ ]
Other information if needed:
The questionnaire is a general social one – questions are on things like health, medical records, and some opinion questions.
During the interview we are recruiting for, they don’t want to answer any question, they don’t have to give an answer. There are no right or wrong answers – our objective is to improve the way we ask questions.
Any information they give will be kept confidential. No identifying information will be associated with the data they provide.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | WEINMAN/SCHNEE, INC |
| Author | Carol Broughton |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |