Form Approved
OMB No. 0923-XXXX
Exp. Date xx/xx/20xx
Ask the participant these questions before beginning the interview.
Script: I’m going to ask you some questions about the people you know. Not including people you live with, think about how many adults (18 and older) you know who were born in Burma or in refugee camps in Thailand or Malaysia or their parents or grandparents who were born in Burma or in refugee camps in Thailand or Malaysia.
Of these people, about how many eat fish caught in the bodies of water that we talked about?
______ people ___ Don’t know ___ Refused
How many of these people would you consider referring to a project like this one?
______ people ___ Don’t know ___ Refused
If there are people you would not refer to this project, why would you not refer all of them? Read list of reasons. (POSSIBLE REASONS WILL BE DEVELOPED DURING FORMATIVE RESEARCH.)
Check all that apply.
___ [Reason 1]
___ [Reason 2]
___ [Reason 3]
___ Other Specify: __________________________________
___ Don’t know ___ Refused
If the participant is not a seed: What is your relationship to the person who gave you the coupon?
___ Friend or acquaintance
___ Co-worker
___ Store owner or employee
___ Other Specify: __________________________________
___ Don’t know ___ Refused
If the participant is not a seed: Would you have considered referring (name of recruiter), the person who referred you?
___ Yes ___ No ___ Don’t know ___ Refused
Public reporting burden of this collection of information is estimated to average 5 minutes per response for total participation, 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 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0923-XXXX).
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | wdw0 |
File Modified | 0000-00-00 |
File Created | 2021-01-28 |