C - Sample Screener

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

Attachment C

SAMPLE SCREENER

Hello, my name is _________ and I am calling on behalf of (enter contractor name if applicable). This project is being sponsored by the Centers for Disease Control and Prevention, also called CDC. We are going to be conducting (focus groups/survey) to better understand (enter topic). We would like to speak with you about your thoughts and opinions on this topic. We are looking for (enter target group) to participate in these discussions. They will last (enter time). To see if you are eligible to participate in this study, I need to ask you some questions. If you are eligible and chose to participate, all of your answers will be kept secure.

1. RECORD GENDER

( ) Female

( ) Male

2. Please stop me when I mention the group that includes your age.

( ) 18 – 24

( ) 25 – 29

( ) 30 – 39

( ) 40 – 49

( ) 50 – 64

( ) 65 – 74

( ) 75 – 84

( ) 85 and older

( ) Refused

3. . Are you:

( ) Married

( ) Never married

( ) Divorced or separated

( ) Widowed

( ) Partnered (or living with a domestic partner)

( ) Refused

4. Have you or a close family member ever had any of the following medical conditions?

(enter medical conditions)

5. What is the last year of school or college you have completed?

( ) Less than High School

( ) High School graduate

( ) Some college

( ) 4-year college graduate

( ) Graduate school

( ) Refused

6. What is your race/ethnicity?

Ethnicity:

( ) Hispanic Origin

( ) Not of Hispanic Origin

( ) Refused to answer

Race:

(please mark all that apply)

( ) American Indian or Alaska Native

( ) Asian

( ) Hawaiian or other Pacific Islander

( ) Black or African American

( ) White or Caucasian

( ) Refused

7. Are you currently employed?

( ) Yes

( ) No

8. Which of the following categories best describe your total, annual household income?

( ) Under $20,000/year

( ) $20,001 - $30,000/year

( ) $30,001 - $40,000/year

( ) $40,001 - $50,000/year

( ) $50,001 - $60,000/year

( ) $60,001 - $80,000/year

( ) $80,001 - $100,000/year

( ) Over $100,000/year

9. In what state or territory do you currently reside?

10. What is your zip code? Please enter only first five digits.

11. Do you have any difficulty reading in English?

( ) Yes .

( ) No

12. Do you have a child who is 5 years old or less?

( ) Yes

( ) No

13.Are you currently pregnant?

( ) Yes

( ) No

( ) Decline to answer

14. Do you plan to get pregnant within the next 12 months?

( ) Yes

( ) No

( ) Decline to answer

15. Do you have a child with a disability?

( ) Yes

( ) No

16. Finally, do you or anyone in your household work for an advertising agency, marketing or marketing research firm, or in any business, organization or agency involved in health or healthcare?

( ) Yes

( ) No

Invitation:

Thank you for answering these questions. As a token of appreciation, you will receive [INSERT INCENTIVE AMOUNT] [INSERT METHOD OF PAYMENT AND DATE]. This is an important research effort and we appreciate your assistance.

Closing for Ineligible Participants:

Thank you for answering all of the questions. You are not eligible to be in this study because [INSERT REASON]. We value your interest in this research study. Thank you for being willing to help us.

Closing for Eligible Participants:

Thank you for answering all of the questions. As a token of our appreciation for your participation in the study, we would like to give you $$$. Please verify for our records the following information: your name, mailing address, email address, and home phone number.

The public reporting burden of this collection of information is estimated to average 10 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: OMB (0920-XXXX)