F - Sample Screener

U.S. Department of Health and Human Services (HHS) OMB Control # 0920-XXXX

Centers for Disease Control and Prevention (CDC) Expiration Date XX/XX/XXXX

Screening Instrument

Qualitative information collection on emerging diseases among the foreign-born in the United States

*Phone call/in-person exchange should last approximately 10 minutes*

Hello, my name is ______________________ and I am calling from [INSERT ORGANIZATION NAME HERE]. I would like to invite you to participate in a group discussion about health information that will be held at_________. We’d like to ask what you think about several health topics including [INSERT DISEASE TOPIC HERE]. Your answers will help the U.S. Centers for Disease Control and Prevention, the “CDC,” improve the health of your community. We have a few brief questions to ask and if you qualify and are interested, we will invite you to take part in a survey or a discussion [INSERT DATE HERE].

1. How old are you? _____ (IF UNDER 18, THANK PERSON AND END CONVERSATION)

2. What is your sex? Male Female

3. Were you born in a country other than the U.S.? Yes No

*(IF PARTICIPANT ANSWERS “NO,” THANK PERSON AND END CONVERSATION—see termination script at end)

4. In what country were you born? _______________________________

5. How long have you been in the U.S.? ___________________________

6. Do you speak a language other than English? Yes No

If yes, what language do you speak? _____________________________

7. Are you able to complete a survey or participate in a discussion? Yes No

(IF NO or UNSURE, THANK PERSON AND END CONVERSATION)

8. Any information that will be shared during this discussion will be kept private. All sessions will be audio-recorded. Are you willing to be recorded? Yes No

(IF NO or UNSURE, THANK PERSON AND END CONVERSATION)

9. Do you have any special needs, which need to be addressed for you to participate such as hearing, visual, or other impairments? Yes No

If yes, please list impairment(s): Hearing Visual Other ________________

Those are all my questions. You do qualify for participation in this discussion, and we would like to invite you to join us on [INSERT DATE]. If you decide to participate, you will be given [INSERT INCENTIVE].

10. Are you willing to participate? Yes No

(IF NO, THANK PERSON AND END CONVERSATION)

(IF YES, PLACE CONTACT INFORMATION BELOW)

First Name: _________________________ Phone Number: ( ) __________________

Best time to contact: __________________

Thank you for your time.

Termination Script: Thank you for answering our questions. Unfortunately you do not meet our selection criteria and so are not eligible to participate in our group discussion. Any information that you have shared thus far will be deleted. Thank you for your time and have a good day/night.

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: PRA 0920-XXXX.