Initial Screener for Focus Group Participants

Attachment 1: Screener for Consumers Form Approved

OMB No. 0920-0990

Exp. Date 09/30/2016

SCREENING QUESTIONNAIRE FOR CONSUMERS

Hello, my name is _______________ and I’m from [name of company]. I’m calling on behalf of the Centers for Disease Control and Prevention (CDC), a Federal agency, about a research study. I’m not selling or promoting any product.

The purpose of this study is to learn more about women’s health and medication use. We will be conducting several online discussions in [insert timeframe] on this topic. These discussions will be conducted over the Internet rather than in-person. To see if you are eligible to participate, I’d like to ask you some questions. If you are eligible and choose to participate, all of your comments will be kept secure. As a token of appreciation for your interest, you will receive $50 at the end of the focus group.

               

Does this sound like something you would be interested in participating in?

[If NO] Thank you for your time.

[If YES] Great. Would it be okay if I ask you a few questions? Some of the questions could possibly make you feel uncomfortable, but your decision to answer the questions is completely voluntary and you skip any question you do not feel comfortable answering and stop answering questions at any time.

For screener only:

Group 1: Women planning to get pregnant in next year who currently take prescription pain medication for chronic pain

Group 2: Women planning to get pregnant in next year who currently take a prescription antidepressant.

Group 3: Women planning to get pregnant in next year who currently take a prescription asthma medication.

Group 4: Women who had a baby in the last year who took a short term medication during pregnancy.

Group 5: Women who had a baby in the last year who took a prescription antidepressant during pregnancy.

Group 6: Women who had a baby in the last year who took a prescription asthma medication during pregnancy.

1. Can you read and write in English?

• Yes CONTINUE

• No TERMINATE

2. What is your gender?

• Female CONTINUE

• Male or Other TERMINATE

3. Do you have access to a computer with Internet that would allow you to take part in a 60-90 minute live, chat session?

• Yes CONTINUE

• No TERMINATE

4. What is your age?    ______________ years [Record age, recruit a mix in categories of 18-24, 25-34, and 35-44]

• 18-44 CONTINUE

• Other TERMINATE

5. Are you currently pregnant?

• Yes TERMINATE

• No CONTINUE

5. Have you given birth in the past year?

• Yes CONTINUE

• No [SKIP TO 6]

5a. Did you take a prescribed medication to treat depression (at any point) during your pregnancy?

• Yes ASSIGN TO GROUP 5; SKIP to Q7

• No CONTINUE

5b. Did you take a prescribed medication to treat asthma (at any point) during your pregnancy?

• Yes ASSIGN TO GROUP 6; SKIP to Q7

• No CONTINUE

5c. How many different types of medication, besides vitamins, did you take during your pregnancy to treat a short-term sickness or to reduce pain or discomfort? (such as Tylenol, an allergy medication, cold medication, antibiotic, nausea pill, etc.?)

• 0 TERMINATE (Terminate if “no” to all Q5 questions)

• 1 ASSIGN TO GROUP 4; SKIP to Q7

• 2-3 ASSIGN TO GROUP 4; SKIP to Q7

• More than 3 ASSIGN TO GROUP 4; SKIP to Q7

6. Are you planning to get pregnant within the next year?

• Yes CONTINUE

• No TERMINATE

6a. Are you currently taking a prescribed medication to treat chronic pain? [can include, but not limited to back pain, migraines, fibromyalgia, etc]

• Yes ASSIGN TO GROUP 1; SKIP to Q7

• No CONTINUE

6b. Are you currently taking a prescribed medication to treat depression?

• Yes ASSIGN TO GROUP 2; SKIP to Q7

• No CONTINUE

6c. Are you currently taking a prescribed medication to treat asthma?

• Yes ASSIGN TO GROUP 3; CONTINUE to Q7

• No TERMINATE (Terminate if “no” to all Q6 questions)

7.    Which of the following categories best describes your total family income (before taxes) from all sources in 2013? [ATTEMPT MIX]

• Less than $30,000     

• Between $30,000 and $75,000

• More than $75,000                  

• Don’t know                                                

8.  What is the highest grade or year of school you completed? [ATTEMPT MIX]

• Grades 1 through 11 (some high school)

• Grade 12 or GED (high school graduate)

• College 1-4 years (some college or college graduate)

• Masters or professional degree (MA, MS, MD, PhD)

9.  Are you Hispanic or Latina? [ATTEMPT MIX]

• Yes

• No  

10.  Which of the following categories best describes your race? [ATTEMPT MIX]

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

• Refused

11. How would you describe where you live? [ATTEMPT MIX]

• Urban

• Suburban

• Rural

12. In what state do you live? _____ [Drop down list of states] [ATTEMPT MIX]

WRAP-UP FOR TERMINATED INDIVIDUALS:

1. Thank you for speaking with us and answering the questions today, but unfortunately you are not eligible to participate in the focus group discussions. All information that you provided today will remain SECURE. If you have any further questions about this project please call XXX-XXX-XXXX. Thank you again.

_____________________________________________________________________________

WRAP-UP FOR ELIGIBLE INDIVIDUALS:

Group Eligibility (Check appropriate box):

	Women planning to get pregnant in next year who currently take prescription pain medication for chronic pain
	Women planning to get pregnant in next year who currently take a prescription antidepressant.
	Women planning to get pregnant in next year who currently take a prescription asthma medication.
	Women who had a baby in the last year who took a short term medication during pregnancy.
	Women who had a baby in the last year who took a prescription antidepressant during pregnancy.
	Women who had a baby in the last year who took a prescription asthma medication during pregnancy.

Schedule for Focus Group:

I would like to invite you to participate in an online, focus group discussion that will be held on [DAY] at [TIME]. As I mentioned earlier, the discussion will last approximately 90 minutes and will be audio-recorded. As a token of appreciation for your interest, you will receive $50 following your participation in the discussion. Would you be willing to participate?

Yes GET CONTACT INFO

No END CALL

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 (0920-0990)