Medical Countermeasures Message Testing
Kelli Bursey, MPH, CHES
Karen Carera, Ph.D.
Dick Tardif, Ph.D.
ORAU
Paula Rausch, Ph.D.
Anne Rowzee, Ph.D.
Food and Drug Administration
Center for Drug Evaluation and Research
Appendix A. Screening Instrument
MCM Message Testing
Screening Instrument
Recruit
3 groups DAY 1
3:30 – 5:00 Low Education Group
5:00 – 6:00 Dinner Break
6:00 – 7:30 Racial/Ethnic Minority Group
8:00 – 9:30 General Public Group
3 groups DAY 2
3:30 – 5:00 General Public Group
5:00 – 6:00 Dinner Break
6:00 – 7:30 General Public Group
8:00 – 9:30 General Public Group
Recruit 10 per group
Good evening. My name is __________________ and I am calling from _______________, a market research firm. Today we are talking with people as part of a study for the Food and Drug Administration (also known as FDA). We are not selling anything. We have a few brief questions that will take just two – three minutes of your time, and if you qualify and are interested, we will invite you to take part in a discussion group with other people in your area that will take place at a later date.
Assess and verify ability to speak and understand English. [Terminate screener as soon as recruiting staff realizes the person does not speak or understand English]
Have you participated in a focus group, intercept interview, telephone survey, and/or online survey in which you were asked your opinions regarding a product, a service, or advertising within the past six months?
01 Yes [THANK AND TERMINATE]
02 No
Do you, or does any member of your household or immediate family work:
01 For a market research company
02 For an advertising agency or public relations firm
03 In the media (TV/radio/newspapers/magazines)
04 As a healthcare professional (doctor, nurse, pharmacist, dietician, etc.)
05 Pharmaceutical Industry
[IF YES TO ANY, THANK AND TERMINATE]
3. Are you an/a:
Employee of U.S. Department of Health and Human Services
Employee of state or local health department
Employee of Department of Homeland Security
Employee of state or local emergency management agency
Biologists, chemists, health physicists or related fields involved with radiological, biological or chemical hazards
IF YES TO ANY OF THE ABOVE, THANK AND TERMINATE
4. In which of the following categories does your age fall?
01 under 18 years of age [THANK AND TERMINATE]
02 18-24 years of age
03 25-34 years of age
04 35-44 years of age
05 45-54 years of age
06 55-64 years of age
07 65-74 years of age
08 75 -80
09 81 and older [THANK AND TERMINATE]
[DOCUMENT ON GRID]
[RECRUIT A MIX WITHIN EACH GROUP]
[RECRUIT SO THAT GROUPS TOGETHER ARE REFLECTIVE OF THE COMMUNITY]
5. What is the highest level of education you have completed?
01 Less than high school graduate/some high school [POSSIBLE RECRUIT FOR LOW EDUCATION GROUP]
02 High school graduate or completed GED [POSSIBLE RECRUIT FOR LOW EDUCATION GROUP OR GENERAL PUBLIC GROUP]
03 Some college or technical school [POSSIBLE RECRUIT FOR GENERAL PUBLIC GROUP]
04 Received four-year college degree [POSSIBLE RECRUIT FOR GENERAL PUBLIC GROUP]
05 Some graduate studies [POSSIBLE RECRUIT FOR GENERAL PUBLIC GROUP]
06 Received advanced certificate or degree [THANK AND TERMINATE]
07 Other: _____________________ [THANK AND TERMINATE]
[DOCUMENT ON GRID]
[RECRUIT ACROSS GROUPS A MIX REFLECTIVE OF THE COMMUNITY]
6. Do you have health insurance?
YES
NO
If no, do you have health coverage like Medicare, Medicaid, TriCare, etc?
YES (RECRUIT as having health insurance)
NO (RECRUIT as having no health insurance)
[DOCUMENT ON GRID]
[RECRUIT A MIX]
7. Gender
01 Male
02 Female
[DOCUMENT ON GRID]
[RECRUIT ABOUT A 50/50 MIX]
8. Are you Hispanic, Latino/a, or Spanish Origin?
(One or more categories may be selected)
Categories
a. ____ No, not of Hispanic, Latino/a, or Spanish origin (SKIP TO QUESTION 9)
b. ____ Yes, Mexican, Mexican American, Chicano/a
c. ____ Yes, Puerto Rican
d. ____ Yes, Cuban
e. ____ Yes, Another Hispanic, Latino/a or Spanish origin
[DOCUMENT ON GRID]
[RECRUIT AT LEAST 3 FOR RACIAL/MINORITY GROUP]
[ALSO RECRUIT A MIX REFLECTIVE OF THE COMMUNITY FOR GENERAL PUBLIC GROUP AND LOW EDUCATION GROUP]
9. Please indicate your race or ethnic background.
a. ____ White
b. ____ Black or African American [RECRUIT AT LEAST 3 FOR RACIAL/MINORITY GROUP]
OTHER [RECRUIT AT LEAST 2 FROM THIS CATEGORY FOR RACIAL/MINORITY GROUP]
c. ____ American Indian or Alaska Native
d. ____ Asian Indian
e. ____ Chinese
f. ____ Filipino
g. ____ Japanese
h. ____ Korean
i. ____ Vietnamese
j. ____ Other Asian
k. ____ Native Hawaiian
l. ____ Guamanian or Chamorro
m. ____ Samoan
n. ____ Other Pacific Islander
[DOCUMENT ON GRID]
[ALSO RECRUIT A MIX REFLECTIVE OF THE COMMUNITY FOR GENERAL PUBLIC GROUP AND LOW EDUCATION GROUP]
10. Do you have children (under the age of 18) living in your household?
01 Yes
02 No
[RECRUIT A MIX; DOCUMENT ON GRID]
That is all of my questions. You do qualify for our discussion group and we would like to invite you to join us on _______ at ______ PM. The discussion will last about 90 minutes; it will be recorded (audio only) to be sure we get all the information. Researchers will be observing the research project either in-person or remotely through live video streaming.
The session will not be video recorded. At the end of the discussion, we will offer you $XXX as a token of appreciation.
Are you willing to participate?
01 yes
02 no
Prior to the start of the group discussion, you will receive an information sheet with such information as sponsorship of the study and contacts for more information. If after we hang up, you have a question about this group discussion or decide you can’t participate, please contact me at ________________.
Name_________________________________________________________________
Address________________________________________________________________
City/State/Zip___________________________________________________________
Day Number_________________________Night Number_____________________
MCM Msg Test Screening instrument Page
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Protocol |
| Author | wernerk |
| File Modified | 0000-00-00 |
| File Created | 2021-01-28 |