Form Screener

Attachment B

Screening and Recruiting Questionnaire

OMB No. 0930-0196

Expiration Date: 09/30/16

Public Burden Statement: 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.  The OMB control number for this project is 0930-0196.  Public reporting burden for this collection of information is estimated to average 90 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, MD 20857.

Screener for Concept Testing

“Talk. They Hear You” PSA aimed Hispanic/Latino Populations Spanish-Dominant Speakers

For each group, recruit 12 participants in anticipation of 10 to show.

PARTICIPANTS SELECTION CRITERIA

• Participants need to be Spanish dominant speakers

• Self-identify as Hispanic/Latinos

• Be able to read and write in Spanish

• Be parents or caregivers of children 9 to 15 years old

• Parents need to live with their children at least part time

• Parents with multiple children in the age group may qualify for one age group only

• Parents/caregivers need to be 18 and older

Each group needs a mix of three segments (per quotas listed below, table 1):

• Parents/caregivers with children 9 to 11 years old

• Parents/caregivers with children 12 to 13 years old

• Parents/caregivers with children 14 to 15 years old

Additionally, each group needs an overall mix of (quotas listed below, table 1)

• Mix of males and females

• Mix of educational levels

• Mix of income levels

• Mix of countries of origin

EXCLUSION CRITERIA

• Hispanic/Latinos 18 years old and older who do not have children 9 to 15 years old

• Hispanic/Latinos 18 years and older who have children ages 9 to 15, but do not live with them/no contact with them

• Hispanic/Latinos who have children younger than 9 years old and older than 15 years old

• Hispanic/Latinos who are English dominant speakers

• Hispanic/Latinos who are available to participate on the planned dates and times

Recruitment Objectives

Recruit 12 parents/caregivers of children aged 9 to 15 (to get ten participants per group) who are willing and available to participate in a FGD session of 90 minutes, preferable at evening hours.

PARTICIPANTS’ QUOTA DISTRIBUTION

	FG1	FG2	FG3	FG4	TOTAL
	WDC (Metropolitan area)	CA Los Angeles (District 14)	TX (San Antonio)	FL (Miami-Dade)	4
Gender
Female	5	5	5	5	20
Male	5	5	5	5	20
Children’s Age
9–11	3	4	3	3	13
12–13	4	3	3	4	13
14–15	3	3	4	3	13
Ethnicity
Hispanic, Latino or Spanish Origin	10	10	10	10	40
Not of Hispanic, Latino, or Spanish Origin	0	0	0	0	0
Country of Origin
Mexico		X	X		At least 2
Puerto Rico		X			At least 2
El Salvador	X				At least 2
Cuba				X	At least 2
Dominican Republic				X	At least 2
Colombia	X				At least 2
Guatemala		X			At least 2
Ecuador		X			At least 2
Venezuela				X	At least 2
Honduras	X				At least 2
Peru	X				At least 2
Nicaragua				X	At least 2
Other	Optional	Optional	Optional	Optional	At least 2 per any country of origin
Education
No HS diploma, nor GED	1	1	1	1	4
HS graduate	3	3	3	3	12
Some college or tech school	3	3	3	3	12
College/Tech grad	2	2	2	2	8
Post-graduate	1	1	1	1	4
Language
English dominant	0	0	0	0	0
Spanish dominant	8	8	8	8	32
Bilingual ENG/SPA	2	2	2	2	8

SCREENING QUESTIONNAIRE

Recruiter: CONDUCT THE SCREENING IN SPANISH [Use the Spanish version]

Hello. My name is ___________________. I work at _____ (organization’s name

We are interested in taking with Hispanic/Latino parents and caregivers who live at least part time with their children ages 9 to 15. The purpose of these conversations is to obtain ideas for a TV spot (called a “PSA”) about underage drinking. As we are beginning the development of this product, we want your participation in the reviewing some concepts that have been developed. We would like to hear from Hispanic/Latino parents about their opinions, suggestions, and concerns about the proposed concepts, to make them more relevant and appealing for this target population.

1. Are you interested in participating in this group session?

⃝ Yes ⃝ No [if No, terminate: “Thank you very much for your time. Have a good day/evening, goodbye.”]

2. Are you available to participate in a 90-minute session during the week of:

[TBA - includes dates and time for each city.]

⃝ Yes ⃝ No [if No, terminate “Based on your availability, we cannot include you this time. Thank you for your interest.”]

Recruiter: I am going to ask you some questions that will indicate whether you qualify to participate in this discussion group.

1. Are you the mother/father or primary caregiver of a child between the ages of 9 and 15?

⃝ Yes - Mother/Father [CONTINUE]

⃝ Yes - Primary caregiver [CONTINUE]

⃝ No - [Thank and terminate.]

2. What age is/are your children? [Recruiter: Do not read. Mark in the appropriate range.]

⃝ 9–11

⃝ 12–13

⃝ 14–15

[If a potential participant has multiple children, select a mother/father only for one age group. Please refer to the quota for each city.]

3. Are you of Hispanic, Latino, or Spanish origin?

⃝ Yes - [CONTINUE]

⃝ No - [Thank and terminate]

4. What is your race? Select all that apply. [Do not read, wait for the response.]

⃝ American Indian/Alaska Native

⃝ Asian

⃝ Black/African American

⃝ Native Hawaiian/Other Pacific Islander

⃝ White

5. Please select which option describes you best.

⃝ I only speak Spanish. [CONTINUE]

⃝ I am a Spanish-dominant speaker. [CONTINUE]

⃝ I am bilingual in English and Spanish. [CONTINUE, but check quota for each city.]

⃝ I am an English-dominant speaker. [Thank and terminate.]

⃝ I only speak English. [Thank and terminate.]

6. What is your country of origin?

⃝ Mexico

⃝ Puerto Rico

⃝ Cuba

⃝ Dominican Republic

⃝ El Salvador

⃝ Guatemala

⃝ Honduras

⃝ Nicaragua

⃝ Colombia

⃝ Ecuador

⃝ Peru

⃝ Venezuela

⃝ Other [Record country.] ____________________

[Attempt to recruit at least two participants from each country of origin. Please refer to the quota for each city.]

7. Gender: ⃝ Female ⃝ Male

[Attempt to recruit five females and five males by group.]

8. Have you talked with your children about drinking alcohol?

⃝ Yes

⃝ No

[Attempt to recruit a mix of participants who have and who have not spoken to their children about alcohol.]

9. What is the highest degree or level of education you have completed?

⃝ No high school diploma, nor GED

⃝ HS graduate or GED

⃝ Some college or tech school

⃝ College/Tech graduate

⃝ Postgraduate

[Attempt to recruit participants with a mix of educational levels. Please refer to the quota for each city.]

Recruiter: “Thank you for answering these questions. If you are selected as a group discussion participant, you will receive a call from me, or/and an e-mail to confirm your participation, and to be informed of the venue, date, and time of the group discussion session. Could you please provide us with information about the best way to contact you?”

Name: _____________________________________________________________________

E-mail: _________________________________Phone/Mobile: _______________________

21