Form 1 Screener - Revised - English

ATTACHMENT E-1: Screening Questionnaire in English

OMB No. 0925-0589

Expiration Date: April 30, 2014

STATEMENT OF PRIVACY: Collection of this information is authorized by The Public Health Service Act, Sections 411 (42 USC 285 a) and 412 (42 USC 285a-1.a and 285a1.3). The purpose of this data collection is to evaluate whether the survey questions are easy to understand. The results of the data collection will be used to improve the survey instrument. Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private under the Privacy Act and will only be seen by people authorized to work on this project. The report summarizing the findings will not contain any names or identifying information. Identifying information will be destroyed when the project ends.

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN: Public reporting burden for this collection of information is estimated to average 90 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0589-09). Do not return the completed form to this address.

INTRO

Screener for the Health Information National Trends Survey

NAME: ______________________________________ R PHONE: ( ) ________ - ___________

DC NAME: _____________________________________ DATE: _____/_____/20 ____

|__| C= Eligible,Can Attend |__| E= Eligible, Can’t Attend Current Date(s)/Time(s)

|__| I= Ineligible |__| QF= Eligible, Cell Quota Filled

NAME____________________________ PHONE__________________________

RESPONDENT Number ____________________

Hello, my name is (NAME) and I’m calling from Westat, a research company in Rockville. May I speak with (NAME)?

[IF NEEDED, RE-INTRODUCE YOURSELF.]

Thank you for your interest in the Health Information National Trends Survey (HINTS). I would like to tell you a little bit about the study and then I’ll ask you a few questions to see if you are eligible to take part.

We’re looking for people to participate in a session that can last about an hour and a half. In that session you would meet with a Westat researcher who would ask you to complete a questionnaire from a survey that we’re developing about how people look for and use health-related information. We need men and women over the age of 18 to take part in the interviews. All the interviews are being conducted at Westat, in Rockville MD, and everyone who participates will receive $50 in appreciation for their time.

May I ask you a few questions to see if you’re eligible to participate.

Westat, a research company in Rockville, Maryland is conducting survey research for the U.S. Department of Health and Human Services to test questions for an upcoming national survey – we’d like to get your opinion on whether the questions are easy to understand and answer.

Q1. As I said, these interviews will take place at Westat’s headquarters, located on Research Boulevard in Rockville, Maryland. Are you within driving or commuting distance of our location?

[IF NEEDED: If driving, take I270, and get off at the Route 28exit towards Darnestown; turn right onto Research Boulevard and go to 1600 Research Blvd.

OR

We’re at 1600 Research Boulevard near the corner of Research and Gude Drive.

OR

If taking Metro, get off at the Rockville Metro station [NEAR SHADY GROVE END OF RED LINE]; THE 63 OR 54 BUS STOPS IN FRONT OF 1600 Research Boulevard.]

1. YES

2. NO – TERMINATE AND THANK: Based on the study design, our interviews are going to be conducted at Westat, so it looks like we can’t include you at this time.

Q2. ASK ONLY IF NOT OBVIOUS: Are you male or female?

• MALE

• FEMALE

Q3. Which of the following age categories are you in?

1. Under 18 – TERMINATE AND THANK: Based on the requirements of this study, it looks like we can’t include you at this time. It is possible we will be calling you in the future for other studies.

2. 18 – 29,

3. 30 – 44,

4. 45 – 54,

5. 55 – 64, OR

6. 65 and older?

[INTERVIEWER: RECRUIT ACCORDING TO OPENINGS POSTED.]

Q4. How many adults age 18 or older live in your household?

Q5. Are you of Hispanic or Latino Origin?

1. YES

2. NO

[INTERVIEWER: RECRUIT ACCORDING TO OPENINGS POSTED.]

Q6. What race do you consider yourself? MARK ALL THAT APPLY.

1. White,

2. Black or African American,

3. Asian

4. American Indian or Alaska Native

5. Native Hawaiian or Other Pacific Islander

[INTERVIEWER: RECRUIT ACCORDING TO OPENINGS POSTED.]

Q7. What is the highest level of education you have completed?

1. 11^th grade or less ,

2. 12 years of school, no diploma,

3. GED or high school graduate (diploma),

4. Some college or technical school,

5. College or technical school graduate, or

6. Post-graduate

[INTERVIEWER: RECRUIT ACCORDING TO OPENINGS POSTED.]

Q8. Have you ever been told by a doctor that you have any of the following health conditions?

1. Asthma?

2. Diabetes?

3. Any type of cancer?

4. Heart disease?

5. High cholesterol?

[INTERVIEWER: RECRUIT ACCORDING TO OPENINGS POSTED.]

Q8b. ASK IF NOT KNOWN: What type of cancer were you diagnosed with?

1. Skin cancer

2. Any other type

[INTERVIEWER: IF SKIN CANCER ONLY, THIS PERSON DOES NOT COUNT TOWARDS OUR QUOTA OF PEOPLE WITH A CANCER DIAGNOSIS.]

Q9. Have you smoked at least 100 cigarettes in your entire life?

a. Yes

b. No

[INTERVIEWER: RECRUIT ACCORDING TO OPENINGS POSTED.]

Q10. In a typical week, about how often do you do any type of exercise?

a. Never

b. once or twice a week

c. three or four times a week

d. 5 or more times a week

[INTERVIEWER: RECRUIT ACCORDING TO OPENINGS POSTED.]

Q11. When was the last time you participated in this type of interview session or a focus group?

a. 6 months ago or less – THANK AND TERMINATE: Based on the requirements of this study, it looks like we can’t include you at this time. Thanks you for your interest.

b. More than 6 months but less than a year –GO TO CLOSING 2.

c. More than a year ago

d. Never

Q12. Do you now or have you ever worked for Westat?

1. YES – THANK AND TERMINATE: Based on the requirements of this study, it looks like we can’t include you at this time. Thanks you for your interest.

2. NO

Q13. Have you ever worked in a job related to health or medicine, for example in nursing, as a lab technician, in medical or public health research, in an HMO office or a health related government agency?

1. YES

2. NO

[INTERVIEWER: RECRUIT ACCORDING TO OPENINGS POSTED.]

Q14. Have you ever heard of the Health Information National Trends Survey?

a. YES – ASK: Where have you heard of it? Are you a researcher who uses or have used HINTS data [IF YES TO USE OF HINTS DATA: “Based on the requirements of this study, it looks like we can’t include you at this time. It is possible we will be calling you in the future for other studies.]

b. NO

Q15. In the interview, we would need for you to read a questionnaire. Would that be a

problem for you?

1. YES– THANK AND TERMINATE: Based on the requirements of this study, it looks like we can’t include you at this time. Thank you for your interest.

2. NO

Q16. In what type of place do you live – a house, apartment or condo, or something else?

1. HOUSE

2. APARTMENT OR CONDO

3. SOMETHING ELSE (SPECIFY)_______________________________________________

[IF GROUP QUARTERS (DORMS, SHELTERS, ETC. Based on the requirements of this study, it looks like we can’t include you at this time. Thank you for your interest.

Q17. What time of day during the week would you be available to participate in an interview?

[NOTE ALL TIMES PERIODS CORRESPONDING TO THEIR GENERAL AVAILABILITY]

a. 7am to Noon

b. Noon to 4pm

b. 4pm to 7pm

c. After 7pm

d. Weekends only

Closing #1

You are eligible to help with this research project. Just to give you a little more information, we’ll be asking people about how they get information about health and their thoughts about health-related topics. Please note, we will not share your personal information with anyone outside of the study staff. Are you interested in participating?

YES — Thank you so much for your willingness to help us. If you are selected as a participant you will receive $50 cash upon completion of the interview. If you are chosen as a participant, I will call you back within a week to set up a time for you to meet with someone from the study team.

NO — Thank you for taking the time to talk with me today. Are you interested in being added to our database as someone who might be interested in participating in future studies like this one?

• YES ADD TO DATABASE.

• NO  Okay. Thank you again for your time today.

Closing #2

Thank you for answering those questions. We will contact you within the next week to indicate if you are eligible to help with this research project.

In the mean time, are you interested in being added to our database as someone who might be interested in participating in future studies like this one?

• YES  ADD TO DATABASE.

• NO  Okay. Thank you again for your time today.

RECRUITING TARGETS:

Characteristic	English Targeted number (22)	Spanish Targeted number (11)
Education
High school or lower	5	5
Some college	5	4
College or more	12	2
Race
African American or other minority	8	--
White	14	--
Male	10	4
Ever diagnosed with cancer	10	4
Ever smoked more than 100 cigarettes	6	4
Exercises at least once during typical week	6	4