Household Survey for General Public_Study Screener

OMB Control No: 0920-xxxx

Expiration Date: xx/xx/20xx

Attachment H: Household Survey for General Public_ Study Screener

Public reporting burden of this collection of information is estimated to average 25 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 Information Collection Review Office; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN:  PRA (0920-xxxx)

Study Screener

Samptype = 1 = Address Based Sample we matched to a phone number

Samptype = 2 = Phone numbers received from return postcards from non-matched address based sample

//ask all//

Introduction:

HELLO, I am calling on behalf of the Centers for Disease Control and Prevention. My name is (name) . We are gathering information from residents of communities that have been affected by tornadoes. Your household has been chosen randomly, and I would like to ask some questions about how your health and well-being were affected by tornados that hit the area in April 2011. This call may be monitored and recorded for quality control.

INTRO1 Is this (phone number) ?

01 Continue

02 No STOP TERM DISP = XX

05 Selected on the line

14 Continue in Spanish

//ask of all//

Intro2 We want to make sure we have contacted a household in the correct area.

1. continue

//ask if samptype=1//

Conf1 Did I reach you at [CATI Insert Address from sample]

1 Yes, correct address [go to hs1]

2 No

7 Don’t know

9 Refused

//if conf1=2,7,9 or samptype = 2//

CNTY What county do you live in?

1 Monroe County, MS

2 Chickasaw County, MS

3 Franklin County, AL

4 Marion County, AL

5 Jefferson County, AL

6 Tuscaloosa County, AL

8 Other County

7 Don‘t know / Not sure

9 Refused

//if cnty = 8,7,9//

Badcnty We are only interviewing residents within specific communities that have been affected by natural disasters. Those are all the questions I have for you today. Thank you for your time.

1. continue [SCREENER DISPO xx]

// ask if cnty = 1-6//

TOWN What town/neighborhood do you live in? (list to be provided)

___ Record Response

07 Don‘t know

09 Refused

//ask if conf1 = 1 or cnty = 1-6//

HS1 Do you live in a private residence?

READ ONLY IF NECESSARY: “By private residence, we mean someplace like a house or apartment.”

1 Yes [Go to state of residence]

2 No, business phone only

//if HS1=2//

BUS Thank you very much but we are only interviewing persons in private residences at this time. DISPO 41

1. continue

//ask if HS1=1 //

HS2 Is this a cellular telephone?

Interviewer Note: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services).

Read only if necessary: “By cellular (or cell) telephone we mean a telephone that is mobile and usable outside of your neighborhood.”

1 No [go to adults]

2 Yes [go to cadult]

3 NOT A SAFE TIME/DRIVING

7 DON’T KNOW / NOT SURE

9 REFUSED

If “Don’t Know”, “Refused”, //If HS2=7,9//

Thank you for your time. STOP //assign dispo 26//

//ask if hs2 =2//

CADULT

Are you 18 years of age or older?

INTERVIEWER: PLEASE CONFIRM NEGATIVE RESPONSES TO ENSURE THAT RESPONDENT HAS HEARD AND UNDERSTOOD CORRECTLY. ASK GENDER IF NECESSARY.

(215)

1 YES, Male Respondent [Go to PVTRESD2]

2 YES, Female Respondent [Go to PVTRESD2]

3 NO [GO TO CADULT2]

4 NOT A SAFE TIME/DRIVING [Go to CB]

7 DON’T KNOW / NOT SURE

9 REFUSED

//If CADULT=7,9//

Thank you very much for your time. STOP TERM DISP = 28

IF "No”, //If CADULT=3//

CADULT2

Is there an adult that also uses this cell phone?

1 YES [GO TO CADULT3]

2 NO

//if CADULT2=2// (no adult uses cell phone)

Thank you very much, but we are only interviewing persons aged 18 or older at this time. STOP //assign term disp = 27//

//if CADULT2=1//

CADULT3

May I speak with him or her?

1 SWITCHING TO RESPONDENT

2 RESPONDENT NOT AVAILABLE/CALLBACK

/if CADULT3=1 go to INTRO1/

/if CADULT3=2 autocode 105, callback/

//ask if hs2=1//

ADULTS

I need to randomly select one adult who lives in your household to be interviewed. How many members of your household, including yourself, are 18 years of age or older?

__ Number of adults [RANGE 0-18]

//if ADULTS = 0 //

X3 I’m sorry we are only interviewing adult residents who are 18 years of age or older.

Thank you.”

1. continue

// if adults=0 assign dispo 27//

//ask if ADULTS = 1//

ONEADULT Are you the adult?

[INTERVIEWER: If "yes," say “Then you are the person I need to speak with.”]

21 Yes and the respondent is Male

22 Yes and the respondent is Female

03 No

//if ONEADULT=03//

ASKGENDR Is the adult a man or a woman?

21 Male

22 Female

//if ONEADULT=03//

GETADULT May I speak with [fill in (him/her) from previous question]?

1 Yes, Adult coming to the phone.[GO TO NEWADULT]

2 No, not here (interview will terminate) [INTERVIEWER SET APPOINTMENT FOR BEST TIME TO REACH ADULT]

//ASK IF ADULTS>1//

MEN How many of these adults are men

__ Number of men [RANGE 0-18]

//ASK IF ADULTS>1//

WOMEN … and how many are women?

__ Number of women [RANGE 0-18]

RANDOMLY SELECT ADULT; Assign selected value: [01-09 Female; 11-19 Male; 21 one male; 22 one female]

//ASK IF ADULTS > 1//

ASFKOR The person in your household that I need to speak with is the [INSERT SELECTED] . Are you the person?

1 Yes

2 No

//if ASKFOR = 2//

GETNEWAD May I speak with him or her?

1 Yes, Adult coming to the phone.[GO TO NEWADULT]

2 No, not here (interview will terminate) [INTERVIEWER SET APPOINTMENT FOR BEST TIME TO REACH ADULT]

3 Go back to Adults question. Warning: A new respondent may be selected. \n&

                    (You need Supervisor's permission to use this option.)

To the correct respondent:

//if getnewad=1 or getadult = 1//

NEWADULT

HELLO, I am calling on behalf of the Centers for Disease Control and Prevention. My name is (name) . We are gathering information from residents of communities that have been affected by natural disasters. Your household has been chosen randomly, and I would like to ask some questions about how your health and well-being were affected by tornados that hit the area in April 2011. This call may be monitored and recorded for quality control.

1. Continue

//ask of all//

YOURTHE1

If the respondent is eligible for participation, proceed to Attachment D: Household Survey for General Public and Consent

Public reporting burden of this collection of information is estimated to average 25 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 Information Collection Review Office; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN:  PRA (0920-xxxx)