Focus Group Screener

Attachment 12A

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Resident Focus Group Telephone Screening Interview Script

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

Thank you for calling me about participating in our focus groups. Let me give you a little background on what we’ll do. A focus group is a small group discussion about a particular topic. In our groups, we want to hear your opinions about the smoke-free policy in your apartment complex. We’re bringing together adults from several different complexes in the area to get a variety of opinions. We also want to have a mix of smokers, nonsmokers, parents, and households without children. You may be in a group that contains a mix of people, but we want you to know that everyone’s opinions are important and equally valuable to us and that everyone will be heard.

On the day of the focus group, we’ll first get your written consent to be part of this research project, and then you will fill out a brief questionnaire. Then we’ll start the focus group discussion. We expect the consent and short questionnaire to take about 10 minutes and the focus group discussion to take about an hour. At the end of the focus group, we’ll give you a $30.00 Visa gift card and have you sign a receipt. The focus groups will be scheduled for the week of ____________.

Do you have any questions? _____________________________________________

_____________________________________________________________________

Does this sound like something you would like to be part of?

• Yes - go to additional screening questions

• No – Thanks for your time!

In order to schedule you for the right focus group, I need to ask you a few questions:

Additional Screening Questions	Response	Eligible to Participate
1) Are you at least 18 years old?	Yes No - Thanks for your time!	Eligible for any group Not eligible
2) What apartment complex do you live in? _____________________________	Apartment complex is smoke-free Smoke-free common areas only	Eligible for outcome or process group– smoke free complex Eligible for outcome or process group– smoke free common areas
3) Do you smoke cigarettes every day, some days, or not at all?	Every day Some days Not at all	Eligible for process group (cannot have more than 6 smokers in this group; if group has 6, assign to outcomes group) Eligible for outcomes group (if group has 6, stop recruitment).
4) Do you have any children under the age of 18? These would include those that live with you as well as those who don’t.	Yes No	Eligible for process group (cannot have more than 6 parents per group; if group has 6 parents, assign to outcomes group) Eligible for outcomes group (if group has 6, stop recruitment).

Based on your answers, you could be in the focus group scheduled for _______________ or ______________. Which would you prefer?

Date of Focus Group_____________________________

Location of Focus Group ________________________________________________

I’d like to end this call with your name, address, and phone number so that we can send a confirmation to you. [READ BACK INFORMATION TO ASSURE THAT EVERYTHING IS CORRECT.]

Name: ___________________________________________________________

Address: ___________________________________________________________

Phone: ___________________________________________________________

Thank you for your time! I’ll send you a reminder today in the mail.

Respondent ID Number (assigned in order that call is received): ______________________

Recruitment Log (To be used while on the phone – data to be transferred to Excel log)

Circle Group to Which Assigned

Respondent ID Number	Date of Process-Oriented, Smoke Free Complex	Date of Outcome-Oriented, Smoke-Free Complex	Date of Process-Oriented, Smoke Free Common Areas only	Date of Outcome-Oriented, Smoke-Free Common Areas Only
	Smoker	Smoker	Smoker	Smoker
	Parent	Parent	Parent	Parent
	Smoker	Smoker	Smoker	Smoker
	Parent	Parent	Parent	Parent
	Smoker	Smoker	Smoker	Smoker
	Parent	Parent	Parent	Parent
	Smoker	Smoker	Smoker	Smoker
	Parent	Parent	Parent	Parent
	Smoker	Smoker	Smoker	Smoker
	Parent	Parent	Parent	Parent
	Smoker	Smoker	Smoker	Smoker
	Parent	Parent	Parent	Parent
	Smoker	Smoker	Smoker	Smoker
	Parent	Parent	Parent	Parent