AN Screener AN Screener

PARTICIPANT SCREENER – Alaska Natives

Participant Name:	Screening Date:
Participant ID Number:	Focus Group Location:

Hello, my name is [insert name] and I work for Kauffman and Associates on behalf of the U.S. Census Bureau. I am talking to you about an opportunity to participate in research that could help improve the U.S. Census forms. We are recruiting participants from different tribal groups, ages, and educational backgrounds to participate in a focus group. If you meet the criteria and decide to participate, you will receive $75 for your participation. The focus group session will take no more than two hours of your time. The sessions will be audio and video recorded, and your confidentiality will be protected. Can you take a few minutes to answer a few questions to determine whether you qualify to participate? (IF THE ANSWER IS YES, CONTINUE; IF THE ANSWER IS NO, THANK THE RESPONDENT AND POLITELY END THE CONVERSATION.)

1. Are you available on [INSERT SCHEDULED DATE AND TIME HERE]?

____Yes ____No

2. How old are you?

______ IF UNDER 18, THANK AND END

Refuse - THANK AND END

Don't know - THANK AND END

3. When was the last time you participated in a research focus group?

________________________

_____Refuse

_____Never

_____Don’t know

IF LESS THAN 12 MONTHS AGO, REFUSE OR DON'T KNOW: THANK AND

END.

4. About how many focus groups have you participated in? __________________________

4a. (IF YES) What were the topics of the focus groups you participated in? _____________________

5. Note gender or confirm if necessary: ____Female ____Male

6. What is your race? Please select one or more.

(Mark all that apply)

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian

5. Native Hawaiian or Other Pacific Islander

6. (DO NOT READ) Some other race

7. What is your village? (You can identify more than one).

_________________________ _________________________

8. Are you a member of one or more tribes? Yes____ No _____

8a. (IF YES) What is(are) the name(s) of your tribe(s)? (You can identify more than one).

___________________________________________________

___________________________________________________

9. Are you a shareholder of one or more ANCSA corporations? Yes____ No _____

9a. (IF YES) What is(are) the name(s) of your corporations(s)?

___________________________________________________

___________________________________________________

10. [ASK IF RESPONDENT HAS NOT PREVIOUSLY REPORTED A COMMUNITY,

ASSOCIATION, OR COUNCIL] Are you a member of a group we have not named, such

as a Community, Association, or Council? Yes____ No _____

10a. (IF YES) What is(are) the name(s) of your group(s)? (You can identify more than one).

___________________________________________________

___________________________________________________

11. Are you enrolled in any tribe(s), village(s), corporation(s), or similar groups?

Yes____ No _____

11a. (IF YES) Which one(s)?

_______________________ Is this federally recognized? Yes____ No _____

Is this state recognized? Yes____ No _____

_______________________ Is this federally recognized? Yes____ No _____

Is this state recognized? Yes____ No _____

_______________________ Is this federally recognized? Yes____ No _____

Is this state recognized? Yes____ No _____

12. [IF A TRIBE, VILLAGE, COMMUNITY, ASSOCIATION, OR COUNCIL IS

REPORTED] At this time, what is your level of engagement with your main [SAY THE TRIBAL ENTITY STATED BY RESPONDENT]?

a. Very active as an elected or appointed leader, council member, or delegate

b. Active, but not an elected or appointed leader, council member, or delegate

c. Occasionally active

d. Not active

13. [IF ANCSA CORPORTATION IS REPORTED] At this time, what is your level of engagement with your main corporation?

a. Very active as an elected or appointed Regional Corporation Officer or Director

b. Active, but not an elected or appointed Regional Corp. Officer or Director

c. Occasionally active

d. Not active

14. Do you live in an Alaskan village for most of the year?

_____Yes, full time ____Occasional visits (social connections and events)

_____ No

14a. (IF YES or Occasional, ASK) What is the name of the village?

_______________  SKIP TO Q.14

14b. (IF NO, ASK) What city or town do you live in for most of the year?

Name of city or town and state:______________________________

15. What is your mother’s race? Please select one or more.

(Mark all that apply)

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian

5. Native Hawaiian or Other Pacific Islander

6. (DO NOT READ) Some other race

15a. (If American Indian or Alaska Native) What is your mother’s tribe? You can say more than one _______________________

16. What is your father’s race? Please select one or more.

(Mark all that apply)

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian

5. Native Hawaiian or Other Pacific Islander

6. (DO NOT READ) Some other race

16a. (If American Indian or Alaska Native) What is your father’s tribe? You can say more than one _______________________

17. What is the highest grade or level of education you have completed?

____Middle school or less

____Less than high school diploma/GED

____High school diploma/GED

____Some college

____College graduate (does not include associate's degree)

____Graduate/professional degree (MA, MS, MD, JD, PhD, etc.)

____Refuse

____Don't know

18. Please tell us how or where you heard about this study. ________________________

19. Did someone in your tribe or village (IF APPLICABLE, or corporation) ask you or nominate you to participate in this focus group? ____Yes ____No

Thanks for answering these questions. If you are selected for the focus group, we will contact you within the next few days. What is the best way to reach you?

Name:___________________________________ Email:______________________________

Phone # 1_________________________________ Phone #2____________________________

Thank you very much!

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