17.8 Survey

OMB #: 0925-0593

Attach B16. LOI2-QUEX-14 Recruitment Screener

Expiration Date: 8/31/2014

Approved February 10, 2011
Protocol Title: Improving Dietary Assessment in Pregnant Women and Children in the National Children’s
Study
Application No.: NA00043877
Principal Investigator: Dr. Frank Witter
Date: February 10, 2011

Screening Script
Improving Dietary Assessment in Pregnant Women and Children in
the National Children’s Study
Hello, my name is __________________ from the Dietary Assessment Study. Thank
you for calling us to hear more about the study. This research study is being done
to determine the best way to collect information about the diets of African American
infants and children.
May I ask you some questions to see if you qualify for the research study?


If person says “No,” thank the person for his/her time and politely end contact.



If person says “Yes,” inform them about use of their private health information (PHI)
that will be collected. Use the following language:

We will be collecting information about you. Your taking part in this is completely
voluntary.
Your information will only be seen by researchers at Johns Hopkins. We try to
make sure that the information we collect from you is kept private and used only for
the research study we are discussing. If you do not agree to continue talking to me, it
will not affect your care at Johns Hopkins.
If you choose not to enroll in the study or do not qualify for the study your personal
health information will be kept in a recruitment database. Can we keep your
information in a recruitment database? Yes□ No□
You can at anytime request that your name and information be removed from the database.
Infants
Is your infant 11-13 months
old? Yes□ No□
Does the infant live with you?
Yes□ No□
Is your infant free of birth
defects and any major chronic
health conditions that would
interfere with feeding?
Yes□ No□
Is your infant African
American?
AA□ Other than AA □

Children
Is your child 24 months – 4.9
years of age? Yes□ No□
Does your child live with you?
Yes□ No□
Is your infant free of birth
defects and any major chronic
health conditions that would
interfere with feeding?
Yes□ No□
Is your infant African
American?
AA□ Other than AA □

Public reporting burden for 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: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593). Do not return the completed form to this address.

Approved February 10, 2011
Protocol Title: Improving Dietary Assessment in Pregnant Women and Children in the National Children’s
Study
Application No.: NA00043877
Principal Investigator: Dr. Frank Witter
Date: February 10, 2011
Do You have internet access?
Do you have internet access?

Yes□ No□
Meets Eligibility Requirements.
Yes□ No□ (if not thank her for her time)

Yes□ No□
Meets Eligibility Requirements.
Yes□ No□ (if no thank her for her time)

If Eligible:
You will be asked to complete 24 hour self administered 24 hour Dietary Recalls (ASA24) on the
computer, and food records, three times over a one month period for your child. You will also
be asked to complete an Acceptability Questionnaire and an Infant/Child Feeding Questionnaire.
Risk:
If you agree to participate in this study there is a risk that confidential information collected from
you could be compromised during collection, storage, or transmission of the data. To protect
against this, study staff will refer to you by your study i.d. number, store any hard copies of your
information in a folder in a locked file cabinet, and use Federal Information Security
Management measures for all data stored in electronic form. All laptops or desktops that will be
used for the study will also use Federal Information Security Management measures.

Cost:
There is no cost to you for participating in this study.
Benefit:
You will not receive any direct benefit from participating in this study.
You will receive $100 incentive for completing this study.

Do you have any questions? Yes□ No□
Question: ____________________________________________________________
Do you think you would like to take part in this research? Yes□ No□
Provide the person with a contact name and number for any further questions about
the study.
Schedule Enrollment Appointment:
Name: ________________________________
Date: _________________________________
Time: _________________________________
Address: _______________________________
Telephone Screening Script June 2008 Version 1

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Approved February 10, 2011
Protocol Title: Improving Dietary Assessment in Pregnant Women and Children in the National Children’s
Study
Application No.: NA00043877
Principal Investigator: Dr. Frank Witter
Date: February 10, 2011

Phone: ________________________________

Telephone Screening Script June 2008 Version 1

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