Focus Group Screener

Form Approved

OMB NO. 0920-XXXX

Exp. Date: xx/xx/xxxx

Attachment 5: Amazing Me Focus Group Screener

1. How old are you?

• IF 18+ → CONTINUE

• IF <18 →THANK AND END

2. Do you have a child who is 3, about to turn 3, or recently turned 4 years old?

• IF YES → CONTINUE

• IF NO → THANK AND END

3. Have you read the book Amazing Me, It’s Busy Being 3!?

• IF YES → CONTINUE

• IF NO → THANK AND END

4. Have you read the book Amazing Me, It’s Busy Being 3! to your child?

• IF YES → CONTINUE

• IF NO → THANK AND END

5. Do you have a child that has been identified with a developmental delay or disability?

• IF YES → THANK AND END

• IF NO → CONTINUE

6. Do you work in the health or medical field?

• IF YES → CONTINUE

• IF NO → SKIP TO Q8

7. Do you work in a family practice or pediatric setting?

• IF YES → THANK AND END

• IF NO → CONTINUE

8. Do you work for an early intervention or special education provider?

• IF YES → THANK AND END

• IF NO → CONTINUE

9. Have you read the book Amazing Me, It’s Busy Being 3?

• IF YES → CONTINUE TO SCHEDULE

• IF NO → THANK AND END

SCHEDULE: Are you willing and able to participate in a 60 minute group discussion on [DATE] at [TIME] at [LOCATION]?

• IF YES → Thanks for your interest. Please put this date on your calendar. We will be in touch shortly with directions and instructions for attending the group discussion.

• IF NO → THANK AND END

THANK: Thank you for your interest in participating in the focus group discussion. Unfortunately we are looking for people who meet different criteria.

Public reporting burden of this collection of information is estimated to average 5 minutes, 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)