7 Recruitment Screener

Appendix 5: Cognitive Interview/Usability Testing – Recruitment Screener

Cognitive Interviewing Recruitment Screener (to be administered by phone)

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[RECRUITER: GOAL IS RECRUIT 120 TOTAL RESPONDENTS WHO WILL PARTICPATE IN BOTH COGNITIVE INTERVIEWS AND USABILTY TESTING. RECRUIT MIX OF GENDER AND AGE, AS SO FOLLOWS:

Age group	Women	Men
18-25	9	9
25-55	33	33
55-65	9	9
65 or more	9	9
Total	60	60

[RECRUITER: APPROXIMATELY HALF OF THE SAMPLE SHOULD CONSIST OF PARENTS OF CHILDREN WITH SPECIAL HEALTH CARE NEEDS.]

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RESPONDENT'S

RECRUITING INTERVIEWER'S NAME ________________________________DATE _______________

SCREENER

Thank you for your interest in the National Survey of Children’s Health questionnaire re-design study. We just have a few questions to ask you to determine if you are able to participate in the Study.

RECRUITER: RECORD GENDER (DO NOT ASK)

Male [ ]

Female [ ]

Into which of the following age groups does your age fall?

Under 18 [ ] [INELIGIBLE]

18 – 24 [ ]

25 – 34 [ ]

35 – 44 [ ]

45 – 54 [ ]

55 – 64 [ ]

65 or older [ ]

Are you the parent or guardian of any children age 17 or younger who live in the same household as you?

Yes [ ]

No [ ] [INELIGIBLE]

[IF “YES” TO PRECEDING QUESTION, ASK:]

Special health care needs include any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impartment or limiting condition that requires medical management, health care intervention and/or use of specialized services or programs. Do any of the children who live in the same household with you have any special health care needs?

Yes [ ]

No [ ]

[RECRUITER: APPROXIMATELY HALF OF THE SAMPLE SHOULD CONSIST OF PARENTS OF CHILDREN WITH SPECIAL HEALTH CARE NEEDS.]

Which of the following best describes your current employment status?

Employed Full-Time [ ]

Employed Part-Time [ ]

Homemaker [ ]

Retired [ ]

Unemployed/Looking for work [ ]

Which of the following best describes your total household income?

Below $30,000 [ ]

$30,000 to below $60,000 [ ]

$60,000 to below $90,000 [ ]

What is the highest level of education you have completed?
Some high school [ ]

High school graduate [ ]

Some college [ ]

College graduate [ ]

Technical/trade school [ ]

Some graduate school [ ]

Graduate Degree [ ]

Are you of Hispanic, Latino, or Spanish origin?

Yes [ ]

No [ ]

Do you identify as African American?

Yes [ ]

No [ ]

Do you currently have health insurance?

Yes [ ]

No [ ]

[IF INELIGIBLE:]

Thank you for taking the time to answer these questions. Based on what you’ve told me, we will not ask you to take part in the study.

[IF ELIGIBLE:]

Thank you for taking the time to answer these questions. We would like to invite you to take part in an hour-long interview session where you will be asked to complete a series of survey question and discuss your answers with a member of our staff. We are conducting this research study to help improve these survey questions to help develop better ways of gathering information on children’s health. To thank you for your time, we will provide you with $50 paid by cash or check. Do you agree to participate in this study as I have described it?

Yes [ ]

No [ ]

[IF “YES” TO THE “SPECIAL NEEDS” QUESTION AND “ELIGIBLE” CASE, READ:]

To help us better determine eligibility for our study, we’re asking parent or guardians to bring any of the following documentation to our interview: A letter you may already have from your specialist, primary care provider, or professional providing support and services, or any letter from your child’s school stating that your child has been diagnosed with a special needs condition. Also, a prescription bottle with your child’s name on the label is acceptable. Will you be able to bring any of these forms of documentation to our interview?

Yes [ ]

No [ ]

[IF “NO” TO DOCUMENTATION QUESTION]

It is important for us to collect information from you and your child’s health provider. After completing the interview, with your permission we would like to send a letter to your child’s health care provider asking to confirm the date and diagnosis of the special health care need of your child. Would you be willing to sign a consent form allowing us to contact your child’s health care provider?

Yes [ ]

No [ ]

[IF “YES” TO “HEALTH INSURANCE QUESTION”]

You previously indicated you have health insurance. Would it be possible for you to bring any of the following documents: Certificate of insurance, statement of benefit, or insurance card?

Yes [ ]

No [ ]

[IF YES, PROCEED WITH SCHEDULING INTERVIEW SESSION. PROVIDE DETAILS ON HOW INTERVIEW WILL BE CONDUCTED (PHONE/IN-PERSON). PROVIDE DIRECTIONS TO RESEARCH FACILITY FOR IN-PERSON INTERVIEWS.] In case we need to get in touch with you, could you provide us with your contact information? (This information will only be used in case we need to reschedule the interview session or mail study materials to you. We will not share this information with a third party.)

NAME______________________________________________________________________________

ADDRESS __________________________________ APT. ______ PHONE ( ) __________________

CITY ___________________________ STATE ______________ ZIP CODE _____________________

Other information if needed:

If you have any questions about the study, please call [NORC 1-800 NUMBER]. If you have questions about your rights as a survey participant, you may call the chairman of the Research Ethics Review Board at [1-800 NUMBER].

Appendix 5 Page 6