Participant Screener and Recruitment Form

Form Approved

OMB No. 0920-0915

Exp. Date XX/XX/XXXX

Participant Screener and Recruitment Script

“Thank you for calling about the study. I would like to ask you a few questions to see if you¹ are eligible, ok?”

1. IF NOT OBVIOUS: What is your gender?

Male 

Female 

1. Where area are you calling from? (read options)

Atlanta, GA 

Detroit, MI 

Oakland, CA 

Philadelphia, PA 

Other (SPECIFY) _________________________________________

3. Do you have sickle cell disease?

Yes 

No  If No, SAY: “Thanks for calling, but you are not eligible for this study. This is just for people with sickle cell disease.”

4. What type of sickle cell disease do you have?

Sickle cell anemia or SS or hemoglobin SS 

Sickle-hemoglobin C Disease or SC or hemoglobin SC 

Hemoglobin sickle beta-thalassemia 

“Something else” or “I don’t know”  ASK 4A

4A. When was it first diagnosed? _______________________

IF IT SOUNDS SUSPICIOUS, SAY: “Thanks – but it doesn’t look like you’re eligible. We want as diverse a group as possible, and it looks like we have enough people with this kind of diagnosis. If we have cancellations, we’ll try to get back in touch to see if you’re still interested.”

5. How old are you?

_____________ years old

READ CATEGORIES IF NECESSARY:

15 - 17 years of age 

18 - 25 years of age 

26 - 35 years of age 

36 or older 

6. We want as diverse a group as possible, so I’m going to ask you some demographic questions. Are you Hispanic or Latino?

Yes, Hispanic or Latino 

No, not Hispanic or Latino 

7. Which of the following best describes you? You may pick more than one. READ CATEGORIES.

American Indian or Alaska Native 

Asian 

Black or African-American 

Native Hawaiian or other Pacific Islander 

White/Caucasian 

Refused 

8A. For adolescents/parents What grade (is your child) in? _____________________

8B. For adults What is the highest level of education that you’ve completed? (Read options):

Grade school 

Less than high school graduate/some high school 

High school graduate or completed GED 

Some college or technical school 

Received four-year college degree 

Some post graduate studies 

Received advanced degree 

Other _______________ 

IF PERSON IS ELIGIBLE AND QUOTA HAS NOT BEEN MET, GO TO 9. OTHERWISE, SAY: We want to get a diverse group of people to participate and it looks like we have enough people who are similar to you. But, if there are cancellations, we’ll get back in touch to see if you’re still interested. Thanks very much for calling.

9. Are you available on [DATE(s)] at [TIME] to participate in a discussion group?

Yes 

No --> If No, SAY: Thanks for calling, but we’re only planning on holding one discussion group at this time. However, if we need to reschedule, can we get back in touch with you?

Yes  No 

The group will be held at [ADDRESS].

We are holding these groups to learn what people with sickle cell disease think is important in helping them manage their disease. We also want to find out the best ways of providing health information to people like you. We are going to use the information we get from the groups to develop informational materials that will help people better manage their sickle cell and avoid complications. As a token of appreciation, you will receive $50 plus up to $25 for travel costs. Do you have any questions about the study?

If yes, answer questions using Project Description.

I would like to get your telephone number so we can call you with a reminder. I’d also like to get your address, so I can send you directions and some more information about the study.

What is your full name? ____________________________________

What is your address? __________________________________________

_______________________________________________________________

What is your e-mail address? _____________________________________

Would you rather get the directions and information about the study by mail, phone, or e-mail?

Mail  Phone  E-mail 

What are your phone numbers? _____________________________________

And which is the best number for contacting you?

______________________________________________________

Would you rather we reminded you about the discussion group by phone, by e-mail, or both by phone or e-mail?

Phone  E-mail  Phone and e-mail 

1 For participants in the adolescent focus group, items will be modified to ask about “your child.”

The public reporting burden of this collection of information is estimated to average 12 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0915)