Household Screener

OMB Control No: 0920-0993

Expiration Date: 09/30/2015

Attachment H: Household Survey for General Public_ Study Screener

Public reporting burden of this collection of information is estimated to average 25 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 Information Collection Review Office; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN:  PRA (0920-0993)

Study Screener and Informed Consent Statement

Study Screener

Samptype = 1 = Address Based Sample we matched to a phone number

Samptype = 2 = Phone numbers received from return postcards from non-matched address based sample

Variables needed from sample:

Address

Name

County

CTYZIP2

Zip

State

Eligible Zips:

35005	35116	35210	35228	35452	35552	38851
35006	35117	35211	35234	35453	35564	38858
35020	35118	35212	35235	35463	35565	38860
35023	35126	35214	35254	35469	35570	38870
35036	35127	35215	35401	35473	35571	38878
35061	35203	35217	35404	35476	35581	39730
35064	35204	35218	35405	35480	35585	39751
35068	35206	35221	35406	35487	35651	39773
35071	35207	35222	35444	35543	35654	39776
35073	35208	35224	35446	35544	38821

NO NAME SCREENER (SCREENER B)

//ASK IF Samptype = 1 or ASK IF Samptype=2 and NAME = blank////

INTRO1. HELLO, I am calling on behalf of the Centers for Disease Control and Prevention. My name is (name) and I work for ICF International. We are gathering information from residents of communities that have been affected by tornadoes. Your household has been chosen randomly, and I would like to ask some questions about how your health and well-being were affected by tornados that hit the area in April 2011. This call may be monitored and recorded for quality control.

Is this (phone number) ?

01 Continue

02 No

14 Continue in Spanish

//ASK IF INTRO1=02//

X1A. Thank you for your time.

01 Continue //GO TO TERMINATION SCREEN//

//ASK IF INTRO1=01 and Samptype=2//

CELL. Is this a cellular telephone?

[Interviewer Note: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services).]

[Read only if necessary: “By cellular (or cell) telephone we mean a telephone that is mobile and usable outside of your neighborhood.”]

1. Yes

2. No

97 DON’T KNOW / NOT SURE

99 REFUSED

//ASK IF CELL=97,99//

X1. Thank you for your time. //TERM ASSIGN DISPO 26//

01 CONTINUE

//ASK IF CELL=01//

CELLSF. Is now a safe time to talk to you.

[Interviewer note: By “safe time” we mean that the respondent is not driving or otherwise engaged in an activity that requires their full attention.]

1. Yes

2. No //TERM. SCHEDULE CALL BACK//

//ASK INTRO1=01 AND SAMPTYPE=01 OR CELL=02 OR CELLSF=01 //

INTRO2. We want to make sure we have contacted a household in the correct area.

1. Continue

//ASK IF INTRO2 = 01//

CONF1. Do you live at //Insert Address//?

01 Yes, correct address

02 No

97 DON’T KNOW

99 REFUSED

//ASK IF CONF1=2,97,99//

ZIP. What is your zip code?

[READ IF NECESSARY: We need your zip code in order to determine whether your area was in the natural disaster zone from the 2011 tornadoes].

____ [RANGE=5]

99997 Don‘t know

99999 Refused

//IF ZIP ne ELIGIBLE ZIPS or ZIP = 99997,99999//

ZIP1. Thank you very much but we are only interviewing persons in specific zip codes affected by natural disasters.

01 Continue //TERM ASSIGN DISPO 25//

//ASK IF =(CTYZIP2=1 and CONF1 = 2,97,99) Or ZIP=ELIGIBLE ZIP CODE or CONF1=1//

CTY. And what county do you live in?

[Interviewer Note: Do not read response options

1. Franklin

2. Marion

3. Jefferson

4. Monroe

5. Chickasaw

6. Tuscaloosa

7. Other

97 Don‘t know

99 Refused

//ASK IF CTY=07,97,99//

NOCTY. Thank you very much but we are only interviewing persons in counties affected by natural disasters.

01 Continue //TERM ASSIGN DISPO 25//

//ASK IF ZIP ne 99997, 99999 or CONF1=01//

HS1. Do you live in a private residence?

[READ ONLY IF NECESSARY: “By private residence, we mean someplace like a house or apartment.”]

01 Yes

02 No, business phone only

//IF HS1=02//

BUS. Thank you very much but we are only interviewing persons in private residences at this time.

01 Continue //TERM ASSIGN DISPO 10//

//ASK IF HS1=01//

ASKFOR. The adult, aged 18 or older, in your household with the most recent birthday has been randomly selected to take this survey. Are you the person?

01 Yes

2. No

3. There are no adults in the household

//ASK IF ASKFOR=03//

X4. I’m sorry we are only interviewing adult residents who are 18 years of age or older.

Thank you.”

01 Continue //TERM ASSIGN DISPO 17//

//ASK if ASKFOR = 02//

GETNAD. May I speak with him or her?

01 Yes, Adult coming to the phone

02 No, not here (interview will terminate) [INTERVIEWER SET APPOINTMENT FOR BEST TIME TO REACH ADULT]

NAME SCREENER (SCREENER A)

//ASK IF Samptype=2 and NAME ne blank//

N_INTRO1. HELLO, I am calling on behalf of the Centers for Disease Control and Prevention. My name is (name) and I work for ICF International. We are gathering information from residents of communities that have been affected by tornadoes. Your household has been chosen randomly, and I would like to ask some questions about how your health and well-being were affected by tornados that hit the area in April 2011. This call may be monitored and recorded for quality control.

Is this (phone number) ?

01 Continue

02 No

14 Continue in Spanish

//ASK IF N_Intro1=01//

N_CELL. Is this a cellular telephone?

[Interviewer Note: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services).]

[Read only if necessary: “By cellular (or cell) telephone we mean a telephone that is mobile and usable outside of your neighborhood.”]

1. Yes

2. No

97 DON’T KNOW / NOT SURE

99 REFUSED

//ASK IF N_CELL=97,99//

N_X1. Thank you for your time. //TERM ASSIGN DISPO 26//

01 CONTINUE

//ASK IF N_CELL=01//

N_CELLSF. Before we get started, I need to ask, is now a safe time to talk to you.

[Interviewer note: By “safe time” we mean that the respondent is not driving or otherwise engaged in an activity that requires their full attention.]

1. Yes

02 No //TERM. SCHEDULE CALL BACK//

//ASK IF N_CELLSF=01 or N_CELL=02/97/99//

SPLT. May I please speak with //INSERT NAME//?

1. Currently speaking with

2. Yes, coming to phone

3. No

4. Not currently available //schedule callback//

5. No one by that name uses phone

97 DON’T KNOW / NOT SURE

99 REFUSED

//ASK IF SPLT=03, 97, or 99//

SPLTa. I’m afraid I need to speak with the sample respondent in order to proceed with the survey. //Insert Name// previously responded to our letter with a postcard providing this number. May I please speak with them?

1. Yes, coming to phone

02 No.

//ASK IF SPLTa=02 or SPLT=05//

SPLTb. Thank you for your time. Unfortunately we can only interview those sampled for this survey. Have a good day.

01 Continue //GO TO TERM SCREEN//

//ASK IF SPLT=02 or SPLTa=01//

N_INT1a. HELLO, I am calling on behalf of the Centers for Disease Control and Prevention. My name is (name) and I work for ICF International. We are gathering information from residents of communities that have been affected by tornadoes. Your household has been chosen randomly, and I would like to ask some questions about how your health and well-being were affected by tornados that hit the area in April 2011. This call may be monitored and recorded for quality control.

01 Continue

//ASK IF SPLT=01 OR N_INT1a=01//

N_INTRO2. We want to make sure we have contacted a household in the correct area.

1. Continue

//ASK IF n_INTRO2 = 01//

N_CONF1. Do you live at //Insert Address//?

01 Yes, correct address

02 No

97 DON’T KNOW

99 REFUSED

//ASK IF N_CONF1=2,97,99//

N_ZIP. What is your zip code?

[READ IF NECESSARY: We need your zip code in order to determine whether your area was in the natural disaster zone from the 2011 tornadoes].

Record Response ____[RANGE=5]

99997 Don‘t know

99999 Refused

//IF N_ZIP ne ELIGIBLE ZIPS or N_ZIP = 97,99//

N_ZIP1. Thank you very much but we are only interviewing persons in zip codes affected by natural disasters.

01 Continue //TERM ASSIGN DISPO 25//

//ASK IF (CTYZIP2=1and N_CONF1 = 2,97,99) Or N_ZIP=ELIGIBLE ZIP CODE OR N_CONF1=1//

N_CTY. And what county do you live in?

[Interviewer Note: Do not read response options]

1. Franklin

2. Marion

3. Jefferson

4. Monroe

5. Chickasaw

6. Tuscaloosa

7. Other

97 Don‘t know

99 Refused

//ASK IF N_CTY=07,97,99//

N_NOCTY. Thank you very much but we are only interviewing persons in counties affected by natural disasters.

01 Continue //TERM ASSIGN DISPO 25//

//ASK IF N_ZIP ne 99997, 99999 or N_CONF1=01//

N_HS1. Do you live in a private residence?

[READ ONLY IF NECESSARY: “By private residence, we mean someplace like a house or apartment.”]

01 Yes

02 No, business phone only

//IF N_HS1=2//

N_BUS. Thank you very much but we are only interviewing persons in private residences at this time.

01 Continue //TERM ASSIGN DISPO 10//

//ASK IF GETNAD=1 //

NEWADT. HELLO, I am calling on behalf of the Centers for Disease Control and Prevention. My name is (name) and I work for ICF International. We are gathering information from residents of communities that have been affected by natural disasters. Your household has been chosen randomly, and I would like to ask some questions about how your health and well-being were affected by tornados that hit the area in April 2011. This call may be monitored and recorded for quality control.

01 Continue