Appendix E
Katrina and Rita Exposures Registry Pilot Screener
Form Approved OMB No. 0923-XXXX Expiration Date: XX/XX/20XX |
________________________________________________________________________
Public Reporting Burden Statement
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 Information Collection Review Office, 1600 Clifton Road, NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX).
________________________________________________________________________
KARE Registry Intro, Screening, and Proxy Scripts
Intro/Screening
INTRO1.
Hello, this is ___________ calling on behalf of the Agency for Toxic Substances and Disease Registry (ATSDR), a federal health agency in the U.S. Department of Health and Human Services. Can I speak to {fill (insert name)}?
[INTERVIEWER: IF ASKED WHY, SAY: We recently sent them a letter and are calling to invite them to participate in the Katrina and Rita Exposures Registry.]
[INTERVIEWER: IF PERSON UNAVAILABLE PROBE AS TO WHY TO DETERMINE IF A CALLBACK VS A PROXY IS NEEDED.]
[IF A PROXY NEEDED, SAY: “Can I speak to the person who is best able to answer questions on behalf of {fill (insert name)}]
1
Named person is available (Go to Intro2)
2 Proxy needed (e.g.
minor, deceased, mentally incompetent, institutionalized,
incarcerated) (Go to P0)
INTRO2.
[INTERVIEWER - READ IF NECESSARY: Hello, this is ___________ calling on behalf of the Agency for Toxic Substances and Disease Registry (ATSDR), a federal health agency in the U.S. Department of Health and Human Services.]
I am calling to invite you to participate in the Katrina and Rita Exposures Registry. ATSDR is developing a registry of people who stayed in FEMA-supplied trailers after Hurricanes Katrina and Rita. We recently sent you a letter about this Registry. I would like to ask you a few questions to see if you are eligible to participate. Also, I want to let you know that this call may be monitored or recorded for quality purposes.
[INTERVIEWER: IF SAMPLE MEMBER MENTIONS THAT THEY DIDN’T RECEIVE THE LETTER, SEE IF THEY WILL CONTINUE ANYWAY WITHOUT IT]
1
Continue (Go to S1)
2 Would like copy of letter (Go to Remail)
S1. Are you 18 years of age or older?
1
Yes (Go to MC1)
2 No
(Go to P0)
8 DON’T KNOW (Go to P0)
9 REFUSED (Go
to P0)
Programming note: Launch to Blaise for MC1. Questions P0 thru P3 program in CATI-CMS.
MC1. How did you hear about the Katrina and Rita Exposures Registry?
[INTERVIEWER: DO NOT READ LIST. CODE ALL THAT APPLY]
Newspaper
Flyer
Website
Radio
television
billboard
poster
Relative/friend
Coworker
Community Meeting
Employer
Phone call from rti (includes answering machine references)
Letter
Other (specify) {max 60 characters}
98. DON’T KNOW
99. REFUSED
[IF MC1=1, 2, 3, 4, 5, 6, 7, or 8 GO TO MC2; ELSE GO TO S_GENDER]
MC2. What was the most memorable feature of the item(s) you heard or saw?
[INTERVIEWER: ENTER COMMENTS. READ THEM BACK TO THE RESPONDENT TO VERIFY THEY ARE CORRECT BEFORE MOVING TO THE NEXT QUESTION.]
{allow 500 characters}
S_GENDER. For survey purposes, I need to confirm if {fill: you are} {if proxy fill: (insert name) is} male or female?
1 Male
2 Female
8 DON’T KNOW
9 REFUSED
S2.
We
have {fill: your} {if proxy fill: (insert name)’s} primary home
address before
Hurricanes Katrina or Rita as:
[LOAD PRELOAD
INFORMATION:
damage_street
damage_city, Damage_state
Damage_zip]
Is this correct?
[INTERVIEWER: IF NO, PLEASE SAY: “This is not the correct primary home address BEFORE Hurricanes Katrina or Rita?”]
[INTERVEWER: IF DON’T KNOW ASK IF THEY CAN ASK SOMEONE OR IF THEY CAN WRITE DOWN THE ADDRESS WE GAVE AND CHECK AND CALL US BACK]
1
Yes (Go to S3)
2 No (Go to S2a_Street)
8 DON’T
KNOW (Go to S3)
9 REFUSED (Go to S3)
S2a_Street.
Please tell me {fill: your} {if proxy fill: (insert name)’s}
primary home address
before
Hurricanes Katrina or Rita.
[INTERVIEWER: PLEASE READ
INFORMATION COLLECTED BACK TO RESPONDENT TO
VERIFY INFORMATION
IS CORRECT.]
ENTER STREET ADDRESS
S2a_City.
(Please tell me {fill: your} {if proxy fill: (insert name)’s}
primary home address
before
Hurricanes Katrina or Rita.)
[INTERVIEWER: PLEASE READ
INFORMATION COLLECTED BACK TO RESPONDENT TO
VERIFY INFORMATION
IS CORRECT.]
ENTER CITY
S2a_State.
(Please tell me {fill: your} {if proxy fill: (insert name)’s}
primary home address
before
Hurricanes Katrina or Rita.)
[INTERVIEWER: PLEASE READ
INFORMATION COLLECTED BACK TO RESPONDENT TO
VERIFY INFORMATION
IS CORRECT.]
PRESS <BACKSPACE> OR BEGIN TYPING TO SELECT THE STATE FROM THE LOOKUP TABLE
S2a_Zipcode.
(Please tell me {fill: your} {if proxy fill: (insert name)’s}
primary home address
before
Hurricanes Katrina or Rita.)
[INTERVIEWER: PLEASE READ
INFORMATION COLLECTED BACK TO RESPONDENT TO
VERIFY INFORMATION
IS CORRECT.]
ENTER ZIP CODE
S3.
{Fill:
Were you} {If proxy fill: Was (insert name)} forced
to evacuate from {fill:
your} {if proxy
fill: his/her} primary
residence after Hurricanes Katrina or Rita?
1
Yes (Go to S4)
2 No (Go to S4)
8 Don’t know/Not
Sure (Go to S4)
9 Refused (Go to S4)
S4.
After Hurricanes Katrina or Rita, did {fill:
you} {if proxy fill: (insert name)} ever
live in a
FEMA-supplied
trailer for at least 7 consecutive days?
1
Yes (Go to Consent1) (If P1=3 (deceased) go to SConsent1a)
2
No (Go to Ineligible)
8 Don’t
know/Not sure (Go to Ineligible)
9
Refused (Go to Ineligible)
SConsent1.
Based on your responses, {fill: you are} {if proxy fill: (insert
name) is} eligible to
enroll in the Katrina
and Rita Exposures Registry.
The survey will take approximately 20 minutes. The purpose of this Registry is to see if enough eligible people who lived in FEMA supplied trailers can be found and if they are willing to participate. We will ask you some questions about when {fill: you} {if proxy fill: (insert name)} lived in the trailers. We will also ask you about other people who might have lived in the trailer and may contact them or you in the future for more information.
All of your answers will be kept private. Answering these questions is voluntary, but important. You can skip any question or stop the survey at any time. If you choose not to participate, {fill: you} {if proxy fill: (insert name)} will not lose any benefits or services that {fill: you} {if proxy fill: he/she} may be receiving from any government agency.
CONTINUE (GO TO CONSENT2)
SConsent1a.
Based
on your responses, {if proxy fill: (insert name) is} eligible to
enroll in the
Katrina and
Rita Exposures Registry.
The
survey will take approximately 5 minutes. We will ask you some
background
questions about {if proxy fill:
(insert name)}. All
of your answers will be kept private.
Answering these questions is voluntary, but important. You can skip
any question or
stop the survey at any time.
1 CONTINUE (GO TO CONSENT2)
SConsent2.
It is possible that some of the
questions I ask might make you remember what
happened after Hurricane Katrina or Rita and may upset you. You can
stop or take a
break at any time.
There are no benefits to you from participating in this survey, but
the success of this Registry may allow us to create a larger
Registry
where many more people can be
enrolled.
If you have any questions or concerns about participating in the Registry, you can call Suzanne Triplett at 1-800-XXX-XXXX. If you have any questions about your rights as a research participant, please contact RTI’s Office of Research Protection toll-free at 1-866-214-2043. You can also contact CDC’s Human Research Protection Office at 1-800-232-4636.
Do you have any questions before we get started?
1 CONTINUE (IF P1=3 (DECEASED), GO TO DEC0 (IN MAIN INSTRUMENT); ELSE GO TO EX0 (IN MAIN INSTRUMENT))
Proxy
P0. [INTERVIEWER:
IF PERSON INDICATED THEY ARE A MINOR, ASK TO SPEAK TO SOMONE OVER
18.
IF SOMEONE OVER 18 COMES TO THE PHONE, READ INFO
BELOW. IF CAN’T GET SOMEONE OLDER
THAN 18,
BREAKOFF AND SET CALLBACK]
[INTERVIEWER
- READ IF NECESSARY: Hello, this is ___________ calling on behalf of
the
Agency for Toxic Substances and Disease Registry
(ATSDR), a federal health agency in the
U.S. Department
of Health and Human Services. I was told that you are the person who
is
best able to answer questions on behalf of {fill
(insert name)}.]
1 Continue (Go to P0a)
P0a.
I am calling to invite you to participate in the
Katrina and Rita Exposures Registry
on behalf of {fill (insert name)}. ATSDR
is developing a registry of people who stayed in FEMA-supplied
trailers after Hurricanes Katrina and Rita.
We recently sent
{fill (insert name)} a letter about this Registry. I would like to
ask you a few questions to see if you are eligible to participate on
behalf of {fill (insert name)}.
Also, I want to let you
know that this call may be monitored or recorded for quality
purposes.
1
Continue (Go to P1)
2 Would like to receive copy of letter (Go
to Remail)
P1. WHY IS A PROXY BEING INTERVIEWED?
[INTERVIEWER- IF
NECESSARY SAY: I just need to confirm the reason {fill (insert
name)} is
not capable of completing the interview right
now.]
1 SERIOUSLY PHYSICALLY
DISABLED, BUT MENTALLY COMPETENT
2 MENTALLY INCOMPETENT
3
DECEASED
4 INSTITUTIONALIZED
5 INCARCERATED
6
UNDER 18
7 OTHER
P2. What is/was your relationship to {fill (insert name)}?
1
Spouse
2 Mother
3
Father
4
Daughter/Son
5 Sister/Brother
6
Grandparent
7 Other
Blood Relative
8 Mother/Father
In-Law
9 Other In-Law
10 Friend
11
Other
P3.
In case we get disconnected and I need to call you back, can you
please give me your name?
{allow 60 characters}
[INTERVIEWER:
IF PERSON IS VERY HESITANT TO PROVIDE THEIR NAME, SAY: “Your
initials
will be fine.”}
[GO TO S1]
Other Scripts
SIneligible.
We sincerely appreciate your willingness to talk with us about the
Katrina and Rita Exposures Registry.
Today we are only looking to talk
with those
that were forced to evacuate their primary residence due to
the hurricanes and who lived in a FEMA supplied trailer
for at least 7 consecutive
days. Thank you very much for participating today. Have
a
good day/evening.
Remail.
What name and address should we use to mail you a letter about the
Registry?
Enter First/Last Name, Address, City, State, Zip
Refusal.
Hello, this is ___________ calling
on behalf of the Agency for Toxic Substances and
Disease Registry (ATSDR), a federal health agency in the U.S.
Department of Health
and Human Services. Can I
speak to {fill (insert name)} {if proxy (fill: P3 answer)}?
[INTERVIEWER:
IF PERSON NOT ALREADY ON PHONE, REREAD PARAGRAPH ABOVE
BEFORE CONTINUING BELOW.]
My supervisor asked me to
follow-up with you concerning a call you received from
one
of our interviewers about a week ago. I understand that you may have
some
concerns about the Registry that I might be able to
address?
[Go to last unanswered question]
Voicemail.
Hello,
I’m calling on behalf of the Agency for Toxic Substances and
Disease
Registry, a federal health agency
in the U.S. Department of Health and Human
Services. We are trying to reach {fill (insert name)} who may have
recently received
information regarding the
Katrina and Rita Exposures Registry.
Please ask {fill (insert name)} to call 1-800-XXX-XXXX to enroll in
the registry. Thank
you.
Callin1.
Hello. Thank you for calling the Katrina and Rita Exposures
Registry. My name is ____________. May I please have
your name or address so that
I can see if you
are in our database of people to contact?
1 Continue (Go to last unanswered question or Intro2)
2
Not in database (Go to Callin2)
Programming note: Launch to Blaise for Callin2
Callin2.
We sincerely appreciate your willingness to talk with us about the
Katrina
and Rita Exposures Registry. While
your name was not selected for
participation
in the Registry at this time, we would like to
collect your contact
information
in the event that we conduct a larger Registry of people
who stayed in FEMA-supplied trailers after
Hurricanes Katrina and Rita.
Can you please provide your first and last name,
address, and telephone number?
[INTERVIEWER:
PLEASE READ INFORMATION COLLECTED BACK TO RESPONDENT TO
VERIFY INFORMATION IS CORRECT.]
FIRST
AND LAST NAME
STREET
CITY, STATE ZIP
PHONE NUMBER
[AFTER CALLIN2, ASK QUESTIONS MC1 AND MC2 BEFORE GOING TO CALLIN3]
Callin3.
We have all your information recorded. Thank you very much for
calling in today.
Have a good day/evening.
| File Type | application/msword |
| Author | Niki Mayo |
| Last Modified By | OS Reviewer |
| File Modified | 2013-01-30 |
| File Created | 2013-01-25 |