Form 0923-0044 Att1_MI_PhoneQs 20140724

Attachment 1

MICHIGAN DEPARTMENT OF COMMUNITY HEALTH

DIVISION OF ENVIRONMENTAL HEALTH

Biomonitoring of Persistent Toxic Substances

in Michigan Urban Fish eaters

Telephone Questionnaire for Scheduling Repeated Appointments

Attachment 4b Revised July 8, 2014

Readability has been calculated using the Fry Readability Formula for determining grade level at the 7^th grade level when sentences containing agency names are omitted.

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Form Approved

OMB No. 0923-0044

Exp. Date/10/31/2015

Note to scheduler: The text in italics and unbold font is instructional or supporting information. Do not read aloud. CIRCLE or WRITE in answers.

Hello. My name is (first name). I am with the Fisheaters Study from the Michigan Department of Community Health. Last year, you participated in the study by answering a questionnaire and providing blood and urine samples. There was a problem with the laboratory equipment and your blood sample was damaged. I’m calling to ask if you are willing to come to another clinic to provide blood and urine samples again. We would also like to ask you the questions on the questionnaire again. We are asking you to repeat the entire clinic process so that all of your information will be current. As before, you will receive up to $75 in Visa gift cards as a thank you for your blood and urine samples and for answering the questionnaire. The clinic will be in Detroit.

Are you willing to come to a clinic to answer the questionnaire and provide blood and urine samples again? Please accept my apologies for the inconvenience.

If NO: That’s fine. Thank you for taking the time to talk with me today.

If YES: Great! I need to ask you a few questions to find out if you can still be part of the study.

Public reporting burden of this collection of information is estimated to average 7 minutes) per response for total participation, 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 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 Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0923-0044).

1. Do you have hemophilia or any other blood clotting or bleeding health problem?

[ ] Yes READ Ineligible Blood Health Problem Script

[ ] No

(Ineligible Blood Health Problem script)

I’m sorry but we cannot include anyone with a blood health problem in the study. You would not be able to give us a blood sample. Thank you for taking the time to talk to me today.

2. Have you had chemotherapy in the past 6 weeks?

[ ] Yes READ Ineligible Due to Chemotherapy Script

[ ] No

(Ineligible Due to Chemotherapy script)

I’m sorry but we cannot include anyone who has had chemotherapy in the past 6 weeks. You would not be able to give the amount of blood needed for this study. Thank you for taking the time to talk to me today.

3. Do you weigh less than 95 pounds?

[ ] Yes READ Ineligible Weight Script

[ ] No

(Ineligible Weight script)

I’m sorry but we cannot include anyone who weighs less than 95 pounds in the study. You would not be able to give the amount of blood needed for this study. Thank you for taking the time to talk to me today.

4. Have you lost more than 15 pounds in the last year?

[ ] Yes READ Ineligible Weight Loss Script

[ ] No

(Ineligible Weight Loss script)

I’m sorry but we cannot include anyone who has lost more than 15 pounds in the last year in the study. Weight loss could affect the amount of chemicals in your blood. Thank you for taking the time to talk to me today.

Questions 6 and 7 are for females. SKIP to Q 8 for males. If unsure of gender, READ Gender script.

(Gender script)

The next questions are for females. Wait for response indicating gender. If no response, ask his/her gender.

5. Indicate whether the person is male or female.

M F

6. Are you currently pregnant?

[ ] Yes READ Ineligible Due to Pregnancy Script

[ ] No

(Ineligible Due to Pregnancy script)

I’m sorry but we cannot include anyone who is pregnant in the study. Thank you for taking the time to talk with me today.

7. Have you breastfed a child in the past 6 months?

[ ] Yes READ Ineligible Due to Breastfeeding script

[ ] No

(Ineligible Due to Breastfeeding script)

I’m sorry but we cannot include anyone who has breastfed a child in the past 6 months in our study. Thank you for taking the time to talk to me today.

If participant is eligible for the study go to Eligible Participant script

(Eligible participant script)

Great! You are eligible to take part in this study. Let’s talk about scheduling an appointment for you.

Your appointment will take about two hours. When you come to the clinic, you will be asked some questions to help us find out how you might come into contact with chemicals. We’ll ask you questions like where you live, your activities, and food you eat. You will receive a $25 gift card as a thank you for answering these questions. You can refuse to answer any of the questions you do not want to answer.

Next, a medical professional will take 83 ml (about 5 ½ tablespoons) of blood from a vein in your arm.  Then, you will be shown to a private room and asked to provide a urine sample in a cup. You will be given another $25 gift card as a thank you for your blood and urine samples. Finally, you will receive another $25 for completing both the questionnaire and giving blood and urine samples, for a total of up to $75 in gift cards.

8. Do you still want to come into the clinic?

[ ] Yes

[ ] No

If NO That’s fine. Thank you for taking the time to talk with me today.

9. If YES Great! Let’s take a look at the available times to find out what works for you. Are there days or times that are better for you?

[ ] Yes

[ ] No

If YES,

Best days ___________________________________________________

Best times ___________________________________________________

10. You could come in at (time/location). Does that work for you?

[ ] Yes

[ ] No If NO, propose another time/location

RECORD Appointment

Date Time Location

______________ _______________ ____________________________

11. Do you have a way to get to (location) for your appointment?

[ ] Yes

[ ] No If NO, offer transportation assistance

Let’s make sure I have your correct name and other contact information.

12. What is your full name? VERIFY spelling

First: ______________________________

Middle initial:_______________________

Last:_______________________________

13. What is your mailing address? (Verify from Contact Form)

Street Number: _ Street Name:__ _________________

Unit: ______________ and (if applicable) P.O. Box: ________________________

City: _______________ __________ State: _______ ZIP Code: ___________

14. Would you prefer me to use an email address to contact you?

Email address: ___________________________________________________

15. I just called you at XXX- XXX-XXXX. READ participant’s phone number. Is this the best phone number to reach you? If YES, SKIP to Q 6.

[ ] Yes

[ ] No

16. Do you have another number where we can reach you?

Phone 2:__________________________  Home  Work  Cell

Phone 3:__________________________  Home  Work  Cell

Phone 4:__________________________  Relative/friend’s name: _______________

Closing script Thank you very much for agreeing to be part of this study again. I will mail some information to you including an appointment reminder, a map, and a consent form. We will also call you a few days before to remind you of your appointment.

Please read the consent form before you come to your appointment. Don’t sign the form until you come in for your appointment.

I will include our phone number in the mailing in case you have questions or need to change your appointment. Do you have any questions that I can answer now? Okay, we’ll see you on (date/time) at (location). Thanks again for taking the time to talk with me today.