Intercept Consent and Screener

Form Approved

OMB No. 0920-XXXX

Exp. Date:

Public Reporting burden of this collection of information is estimated at 30 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 NW, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-XXXX).

Older Adult Safe Mobility Assessment Tool Development:

Intercept Consent and Screener

INTRODUCTION & VERBAL CONSENT

Hello, I am _____ from a research firm, and we are not selling anything. We are working with the Centers for Disease Control and Prevention to develop a resource that can help people ages 60 or older protect their ability to get places they need to go as they age. We’re looking for people to participate in a short interview we’re conducting here today only. Our research involves showing you 2 versions of this resource, having you read them over and fill them out, and then answering a few questions we have to get your feedback and opinions. It’ll take about 30 minutes, and you will be provided with a thank you gift for participating in our study, which I will tell you more about in a moment.

First, I need to read to you some background on this study and ask for your consent to participate:

All information collected in this research will remain secure. We will take notes and make an audio recording of our interview so that we can create a report, and that data will be kept in locked cabinets, separated from your name in order to keep it secure. For the purposes of reporting results from our research, the information you provide will be grouped with data that others provide, and your name will not be used for any reason. Your voice recording will not be played to others besides the research team without your written permission.

This study is not designed to help you personally; rather the research team hopes to use your and several other peoples’ opinions to make improvements to the resource. Risks of your participation in this interview are expected to be minimal in nature because questions are focused on your opinions of a resource that can help people protect their ability to get places they need to go as they age. You are free to ask questions or withdraw from participation at any time and without penalty, and I can provide you with the lead investigator’s contact information at any time upon your request.

Do you have any questions at this time?

Do you verbally consent to participate in this brief interview today and agree to continue with our conversation? [IF YES, SKIP TO SCREENING QUESTIONS] [IF NO: We’ll be here until _____ pm today. Would you be able to come back at a more convenient time today instead of now?; IF YES, SCHEDULE FOLLOW UP SCREENING.]

SCREENING QUESTIONS

Please tell me to which of the following age groups do you belong?

1. Less than 60 years [ASK IF THERE IS ANYONE WITH THEM TODAY WHO IS BETWEEN 60-74; TERMINATE]

2. 60 to 74 years [CONTINUE]

3. 75 or more years [ASK IF THERE IS ANYONE WITH THEM TODAY WHO IS BETWEEN 60-74; TERMINATE.]

Mix of male (n=15-20) and female (n=20-25) [DO NOT ASK UNLESS UNSURE.]

How would you describe your ability to get where you need to go today? Would you say it is…?

Very good

Good

Fair [ASK FOR CLARIFICATION; IF IT’S FOR HEALTH REASONS, TERMINATE. IF IT’S ACCESS TO TRANSPORTATION, FINANCIAL OR OTHER, KEEP]

Poor [TERMINATE]

Great, you qualify for our study! We need to get participants from a mix of backgrounds, so we have a few more questions that help us do that.

Are you of Hispanic or Latino origin or descent?

Yes

No

Which of the following best describes your race?

White

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native

Please identify which of the following ranges matches your total household income as best you know it.

Under $25,000

Between $25,001 and $35,000

Between $35,001 and $50,000

Between $50,001 and $75,000

$75,001 and $125,000

Greater than $125,000

What is the highest level of education you have completed?

Less than high school

High school diploma/GED

Some college

4-year college degree

Graduate degree/more than 4-year degree

Please tell me your marital status. Are you…?

Single

Married

Widowed

Divorced

Great, let’s get started with the interview!