Telephone Survey Consent and Screener

Form Approved

OMB No. 0920-XXXX

Exp. Date:

Public Reporting burden of this collection of information is estimated at 40 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:

Telephone Survey Consent and Screener

INTRODUCTION & VERBAL CONSENT

Hello, this is _____ 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 phone survey that we’ll be conducting in the coming weeks to get opinions about the resource that’s been developed in order to help us make improvements to the resource. The study will involve this discussion to see if you qualify and consent to participate; then we will mail or e-mail you a document to review and complete; and then we’ll call you and ask you questions over the phone. The questions over the phone will be in the form of a 12-minute survey to get your feedback on the document we sent you. You won’t have to make any special trips anywhere in order to participate. 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 survey will remain secure, and your feedback 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. We are audio recording this survey to assist with our reporting, however your voice 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 interview and agree to continue with our conversation? [IF NO] Would there be another time that would be more convenient for you? [IF YES, SCHEDULE FOLLOW UP SCREENING.]

May I ask you a few questions to see if you qualify to participate in the study? [IF YES, CONTINUE. IF NO, THANK AND TERMINATE].

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

1. Less than 60 years [ASK IF THERE IS ANYONE IN HOUSEHOLD WHO IS BETWEEN 60 AND 74. IF “YES”, ASK TO SPEAK WITH THEM AND REINTRODUCE THE STUDY.]

2. 60 to 74 years [CONTINUE]

3. 75 or more years [ASK IF THERE IS ANYONE IN HOUSEHOLD WHO IS BETWEEN 60 AND 74. IF “YES”, ASK TO SPEAK WITH THEM AND REINTRODUCE THE STUDY.]

QUOTA: males [min = 400, max = 500] and females [min = 500, max = 600] [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. QUOTAS TO BE ADDED AT TIME OF RECRUITMENT TO REFLECT NATIONALLY REPRESENTATIVE SAMPLING.

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, we’d like to invite you to participate. Before I get mail or e-mail address information from you, I have just a few questions.

What is the first thing that comes to mind when you think about challenges you might face in getting to the places you need to go to, as you get older? [WRITE IN]

On a scale of 1 to 5 with one being “not at all,” and 5 being “very much,” how much have you been recently thinking about your ability to get around in your home and community as you age?

On a scale of 1 to 5 with one being “not at all,” and 5 being “very much,” how much have you been recently thinking about protecting your ability to get around your home and community as you age?

Again on a scale of 1-5 with one being “not at all”, and 5 being “very much”, how confident do you feel that you know what to do to protect your mobility as you age?

Again on a scale of 1-5, how motivated are you to protect your ability to get around your home and community as you age?

Great, and thanks again for agreeing to be part of this survey. We’ll mail or e-mail you a copy of the resource we mentioned earlier so that you can read it over and fill it out before we call you to conduct the survey by phone. You won’t have to make any special trips anywhere in order to participate. May I please get your name and either a mailing address or e-mail address from you so that we can send you a copy of the resource.

____________________________________________________________________________

Name E-mail

_______________________________________________

Street Address

_______________________________________________

City, State, Zip Code

Now, let’s set up a time for us to call you to talk with you about the resource. You will be able to fill out the resource without any help. Please do so before our scheduled call and have it available for the phone discussion.

Recall that the survey will only take about 12 minutes. Our office is open ________ [CHECK TIME ZONE]. What day would you be available the week of _______? What would be the best time of day for you? __________