Form 1 Patient Screener

Health Center Patient Survey

Cognitive Interview Screening Form

INTERVIEWER:

• PATIENTS 18 YEARS OF AGE AND OLDER CAN BE APPROACHED DIRECTLY.

• PATIENTS 13-17 YEARS OF AGE, A PARENT/GUARDIAN NEEDS TO BE READ THE INTRO AND CHILD CAN COMPLETE THE SCREENING QUESTIONS WITH PARENT’S APPROVAL.

• PATIENTS 12 YEARS OF AGE AND YOUNGER, ONLY PARENTS CAN BE SCREENED.

Hello, this is [NAME] from RTI International. (Were you calling about the [ad/flyer]?)

PS1. First, just let me verify: Are you 18 or older? YES _________ (GO TO PS2)

NO _________ (GO TO PS3)

PS2. Are you calling on behalf of a child who is less than 13 years old? YES _______ (GO TO PS4)

NO _______ (GO TO INTRO ADULT)

PS3. Are you between 13 and 17 years of age? YES _______ (ASK TO TALK TO PARENT/GUARDIAN AND GO

TO INTRO PROXY 13-17 YEARS OLD)

NO _______ (IF YOUNGER THAN 13, ASK TO TALK TO

PARENT/GUARDIAN AND START WITH

QUESTION PS1)

PS4. Are you this child’s parent or legal guardian? YES _______ (GO TO INTRO PROXY LESS THAN 13

YEARS OLD)

NO _______ (R NOT ELIGIBLE – THANK R AND END)

INTRO ADULT

Let me tell you a little about the study. We are testing a questionnaire about health care received by patients of health centers. This questionnaire will eventually be provided to patients across the country. We are testing these survey questions with different people to see how well the questions work. We want to know: Do they make sense? How easy or difficult are they to answer? We want to understand what you think each question means and how you arrive at your answers. This will help us find out whether there are any problems with the questionnaire. Your feedback will help us during the development of the survey questionnaire. There are no right or wrong answers. We will not ask about your legal situation nor your immigration status.

If you are interested and eligible, we would like to schedule an in-person interview, which will take about 75 minutes. At the end of the interview you will receive $50 in cash. To make sure (you are eligible for the study,; I need to ask you a few brief screening questions. This will only a few minutes. Is this a good time?

INTRO PROXY (13-17 YEARS OLD)

Let me tell you a little about the study. We are testing a questionnaire about health care received by patients of health centers. This questionnaire will eventually be provided to patients across the country. We are testing these survey questions with different people to see how well the questions work. We want to know: Do they make sense? How easy or difficult are they to answer? We want to understand what your child thinks each question means and how he/she arrives at his/her answers. This will help us find out whether there are any problems with the questionnaire. There are no right or wrong answers. We will not ask about his/her legal situation nor his/her immigration status.

If your child is interested and he/she is eligible, we would like to schedule an in-person interview, which will take about 75 minutes. At the end of the interview your child will receive $50 in cash. To make sure he/she is eligible for the study, I need to ask him/her a few brief screening questions. Or, you can answer on his/her behalf. This will only a few minutes. Is this a good time?

INTRO PROXY (LESS THAN 13 YEARS OLD)

Let me tell you a little about the study. We are testing a questionnaire about health care received by patients of health centers. This questionnaire will eventually be provided to patients across the country. We are testing these survey questions with different people to see how well the questions work. We want to know: Do they make sense? How easy or difficult are they to answer? We want to understand what you think each question means and how you arrive at your answers. This will help us find out whether there are any problems with the questionnaire. Because your child is less than 13 years old, we would like to ask you to answer questions and get your feedback, which will help us during the development of the survey questionnaire. There are no right or wrong answers. We will not ask about your legal situation nor your immigration status.

If you are interested and you are eligible, we would like to schedule an in-person interview, which will take about 75 minutes. At the end of the interview you will receive $50 in cash. To make sure you are eligible for the study, I need to ask you a few brief screening questions. This will only a few minutes. Is this a good time?

INTERVIEWER:

FOR ADULTS THE SCREENING QUESTIONS WILL BE ABOUT THEMSELVES.

FOR PARENTS/GUARDIANS OF CHILDREN LESS THAN 13 YEARS OLD AND ADOLESCENTS 13-17 YEARS OLD, ALL SCREENING QUESTIONS WILL BE ABOUT THE CHILD.

S1. (Have you/Has your child) received services from a health care professional such as a doctor, nurse, drug counselor, mental health counselor, or dentist at {THE REFERENCE HEALTH CENTER / A HEALTH CENTER} in the last 12 months?

YES 1 GO TO S1a

NO 2 (R NOT ELIGIBLE – THANK R and END)

REFUSED 7 (R NOT ELIGIBLE – THANK R and END)

DON’T KNOW 9 (R NOT ELIGIBLE – THANK R and END)

S1a. IF HEALTH CENTER NOT KNOWN: What is the name of the health center (you/your minor child) visited in the past 12 months? ___________________________________________________

S2. What is (your/child’s) age? ______ YEARS

S3. IF S2=13-17: Are you currently living with a parent or guardian?

YES 1

NO 2 (R NOT ELIGIBLE – THANK R and END)

S4. RECORD GENDER. (IF NECESSARY, ASK: (Are you/Is your child) male or female?

FEMALE……………..1

MALE………………...2

S5. In what country (were you/was your child) born? (SPECIFY COUNTRY ON SCREENING FORM.)

U.S. 1 GO TO S1a

OTHER………………..2 SPECIFY ________________________________

S6. Do you consider (yourself/your child) to be Hispanic or Latino(a)?

YES 1

NO 2

REFUSED 7

DON’T KNOW 9

S7. What is (your/your child’s) ancestry or ethnic origin? Are you…

1=Mexican, Mexican American, Mexicano or Chicano

2=Puerto Rican

3=Central American

4=South American

5=Cuban or Cuban American

6=Dominican (From Dominican Republic)

7=Spanish (From Spain)

8=Other Latin American, Hispanic, Latino or Spanish Origin (Specify)_____________________

S8. What race or races do you consider (yourself/your child) to be? You may select all that apply.

Are you…

1=White

2=Black or African American

3=American Indian or Alaska Native (American Indian includes North American, Central American, and South American Indians)

4=Native Hawaiian

5=Guamanian or Chamorro

6=Samoan

7=Tongan

8=Marshallese

9=Asian Indian

10=Chinese

11=Filipino

12=Japanese

13=Korean

14=Vietnamese

15=OTHER (SPECIFY)

S8a. (Do you/Does your child) speak Spanish as your native or primary language?

YES…….. 1

NO……… 2

S8b. In addition to Spanish, (do you/does your child) speak any English?

YES…….. 1

NO……… 2

S9. How well (do you/does your child) speak English? Would you say….

1. Very well

2. Well

3. Not well

4. Not at all

ELIGIBILITY: IF RESPONDENT MEETS THESE CRITERIA – CONTINUE WITH COLLECTION OF CONTACT INFORMATION, OTHERWISE THANK THEM FOR THEIR TIME AND EXPLAIN THAT THEY DO NOT MEET THE REQUIREMENTS OF THE STUDY

S1 ONLY YES RESPONSE ELIGIBLE

S3 ONLY YES RESPONSE ELIGIBLE

NAME: ___________________________________________

GENDER: ( ) MALE ( ) FEMALE

TELEPHONE #: ____________________________ ALTERNATE TELEPHONE # ____________________________

BEST TIME TO CALL: ________________

Version: April 18, 2013