Form Approved
OMB No. 0920-0800
Exp. Date 12/31/2017
Attachment H:
Screening Instrument for
Ashkenazi Jewish
Young Women
Public reporting burden of this collection of information is estimated to average 3 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0800)
Screening Instrument: Ashkenazi Jewish Young Women (for recruiters in New York only)
Hello, my name is ______________ and I am calling from _______________ a professional market research firm. I am not selling anything. We’re currently conducting focus groups for the Centers for Disease Control and Prevention.
Information from these discussions will be used to develop educational materials for young women about a health issue. May I ask you a few questions to see if you are eligible to participate in this project? This will take less than five minutes. [IF RESPONDENT INDICATES THAT THIS IS NOT A GOOD TIME, SCHEDULE A CALL BACK TIME]
Document gender. [ASK IF UNSURE]
_____ Female (CONTINUE)
_____ Male (THANK AND TERMINATE)
How old are you? [READ RANGES]
_____ 17 years old or younger (THANK AND TERMINATE)
_____ 18-29 years (RECORD; CONTINUE)
_____ 30-44 years (RECORD; CONTINUE)
_____ 45 years old or older (THANK AND TERMINATE)
Think about both your mother and father’s side of the family. Include your parents, children, brothers/sisters, aunts/uncles, nieces/nephews, and grandparents.
Is there any history of breast or ovarian cancer in your family?
_____ Yes (RECORD; IF 18-29 YEARS OLD [Q2] RECRUIT 9; CONTINUE)
(RECORD; IF 30-44 YEARS OLD [Q2]; THANK AND TERMINATE)
_____ NO (RECORD; IF 30-44 YEARS OLD [Q2] RECRUIT 9; CONTINUE)
(RECORD; IF 18-29 YEARS OLD [Q2]; THANK AND TERMINATE)
Do you own a smart phone?
_____ Yes (CONTINUE)
_____ No (THANK AND TERMINATE)
Which of the following do you do multiple times per week?
[ ] Read email TERMINATE IF EMAIL-ONLY
[ ] Send email TERMINATE IF EMAIL-ONLY
[ ] Search using Google RECORD AND CONTINUE
[ ] Read news articles online RECORD AND CONTINUE
[ ] View Facebook timeline RECORD AND CONTINUE
[ ] Write Facebook posts/comments RECORD AND CONTINUE
[ ] View Twitter feed RECORD AND CONTINUE
[ ] Post tweets RECORD AND CONTINUE
[ ] Watch YouTube videos RECORD AND CONTINUE
[ ] Upload YouTube videos RECORD AND CONTINUE
[ ] Leave comments on YouTube RECORD AND CONTINUE
[ ] View photos online RECORD AND CONTINUE
[ ] Upload photos online RECORD AND CONTINUE
[ ] Read blogs RECORD AND CONTINUE
[ ] Write blog posts RECORD AND CONTINUE
[ ] Other: ____________________ RECORD AND CONTINUE
Do you use the internet for at least 2 hours each week?
_____ Yes (CONTINUE)
_____ No (THANK AND TERMINATE)
Do you or any member of your household work as an employee or contractor in any of the following areas?
_____ Public health, like the Centers for Disease Control and Prevention (CDC), local or state health department, or other public health organization
_____ Medical professions, such as is in a health clinic; doctor or dentist’s office; hospital;
medical laboratory or research institution; health insurance company or agency; or pharmacy or pharmaceutical company
(IF “YES” TO ANY OF THE ABOVE, THANK AND TERMINATE)
Are you of Ashkenazi Jewish descent, that is are you descended from Central or Eastern European Jews?
_____ Yes (RECORD AND CONTINUE)
_____ No or Doesn’t Know (THANK AND TERMINATE)
How would you best describe yourself as a Jewish person [read both options below]:
_____ “Practicing” or “Religious” [If participant asks for clarification: “regularly attend Jewish religious services at a synagogue, temple, minyan (MIN-yin) or Havurah (hah-vu-RAH)”]
_____ “Cultural”, “Non-Practicing”, or “Non-Religious”
(RECRUIT A MIX; RECRUIT AT LEAST 3 PRACTICING/RELIGIOUS IN EACH GROUP)
Have you ever been diagnosed by a doctor with breast cancer or ovarian cancer?
_____ Yes (THANK AND TERMINATE)
_____ NO (RECORD AND CONTINUE)
Have you ever undergone genetic counseling with a licensed genetic counselor regarding cancer-related concerns? This does not include a conversation with a doctor or nurse.
_____ Yes (THANK AND TERMINATE)
_____ NO (RECORD AND CONTINUE)
Have you ever undergone genetic testing related to cancer or your risk for developing cancer (such as testing for a BRCA1 or BRCA2 gene mutation)?
_____ Yes (THANK AND TERMINATE)
_____ NO (RECORD AND CONTINUE)
What is the highest level of education you have completed?
(RECRUIT A MIX; AT LEAST HALF MUST HAVE SOME COLLEGE OR MORE)
01 High School Diploma or less (RECORD; RECRUIT A MIX; CONTINUE)
02 Some college or associates degree (RECORD; RECRUIT A MIX; CONTINUE)
03 College degree (RECORD; RECRUIT A MIX; CONTINUE)
04 Master’s degree (RECORD; RECRUIT A MIX; CONTINUE)
05 JD or PhD (RECORD, RECRUIT A MIX; LIMIT 1 PER GROUP; CONTINUE)
What is your marital status?
______Currently married or in a legal/state registered domestic partnership
______ Not Married (may include divorced, widowed, separated, and never married)
(RECORD; RECRUIT A MIX OF MARRIED/NOT MARRIED; CONTINUE)
Do you have children?
_____ Yes (RECORD AND CONTINUE)
If so, record how many children, their sexes, and ages: _______________________
_____ NO (RECORD AND CONTINUE)
(RECORD; RECRUIT A MIX OF MOTHERS/NOT MOTHERS; CONTINUE)
What is your estimated annual household income? (RECORD; RECRUIT A MIX)
_____ $25,000 or less
_____ Between $25,000 - $49,000
_____ Between $50,000 - $100,000
_____ More than $100,000
ASSESS AND VERIFY ABILITY TO SPEAK AND UNDERSTAND ENGLISH
Those are all of my questions. You qualify and we would like to invite you to participate in a focus group. The discussion will last about 2 hours and will be audio and video recorded. In appreciation for your time, you will be given $75 after completing the focus group. It’s important to know that none of the information you provide us during the focus group will ever be linked to your name in any way.
Are you willing to participate?
_____ Yes (CONTINUE)
_____ NO (THANK AND TERMINATE, ASK IF THEY CAN SUGGEST A PEER THAT MAY BE INTERESTED)
Groups are scheduled for the following times (INSERT DATES AND TIMES – OFFER AT LEAST ONE EVENING GROUP), which of these works with your calendar?
Prior to the start of the focus group, you will receive information for the focus group. If after we hang up, if you have a question about the focus group or decide you can’t participate, please contact me at___________________.
Now, can you please tell me the following information about yourself?
Name________________________________________________________________________
Mailing Address (include zip code) _____________________________________________________________________________
Email Address__________________________________________________________________
Day Number_________________________ Evening Number____________________________
Mobile Phone (if available) ______________________ Fax (if available) __________________
Screening Instrument: Ashkenazi Jewish Young Women (for recruiters in Chicago only)
Hello, my name is ______________ and I am calling from _______________ a professional market research firm. I am not selling anything. We’re currently conducting focus groups for the Centers for Disease Control and Prevention.
Information from these discussions will be used to develop educational materials for young women about a health issue. May I ask you a few questions to see if you are eligible to participate in this project? This will take less than five minutes. [IF RESPONDENT INDICATES THAT THIS IS NOT A GOOD TIME, SCHEDULE A CALL BACK TIME]
Document gender. [ASK IF UNSURE]
_____ Female (CONTINUE)
_____ Male (THANK AND TERMINATE)
How old are you? [READ RANGES]
_____ 17 years old or younger (THANK AND TERMINATE)
_____ 18-29 years (RECORD; CONTINUE)
_____ 30-44 years (RECORD; CONTINUE)
_____ 45 years old or older (THANK AND TERMINATE)
Think about both your mother and father’s side of the family. Include your parents, children, brothers/sisters, aunts/uncles, nieces/nephews, and grandparents.
Is there any history of breast or ovarian cancer in your family?
_____ Yes (RECORD; IF 18-29 YEARS OLD [Q2] THANK AND TERMINATE)
(RECORD; IF 30-44 YEARS OLD [Q2]; RECRUIT 9; CONTINUE)
_____ NO (RECORD; IF 30-44 YEARS OLD [Q2] THANK AND TERMINATE)
(RECORD; IF 18-29 YEARS OLD [Q2]; RECRUIT 9; CONTINUE)
Do you own a smart phone?
_____ Yes (CONTINUE)
_____ No (THANK AND TERMINATE)
Which of the following do you do multiple times per week?
[ ] Read email TERMINATE IF EMAIL-ONLY
[ ] Send email TERMINATE IF EMAIL-ONLY
[ ] Search using Google RECORD AND CONTINUE
[ ] Read news articles online RECORD AND CONTINUE
[ ] View Facebook timeline RECORD AND CONTINUE
[ ] Write Facebook posts/comments RECORD AND CONTINUE
[ ] View Twitter feed RECORD AND CONTINUE
[ ] Post tweets RECORD AND CONTINUE
[ ] Watch YouTube videos RECORD AND CONTINUE
[ ] Upload YouTube videos RECORD AND CONTINUE
[ ] Leave comments on YouTube RECORD AND CONTINUE
[ ] View photos online RECORD AND CONTINUE
[ ] Upload photos online RECORD AND CONTINUE
[ ] Read blogs RECORD AND CONTINUE
[ ] Write blog posts RECORD AND CONTINUE
[ ] Other: ____________________ RECORD AND CONTINUE
Do you use the internet for at least 2 hours each week?
_____ Yes (CONTINUE)
_____ No (THANK AND TERMINATE)
Do you or any member of your household work as an employee or contractor in any of the following areas?
_____ Public health, like the Centers for Disease Control and Prevention (CDC), local or state health department, or other public health organization
_____ Medical professions, such as is in a health clinic; doctor or dentist’s office; hospital;
Medical laboratory or research institution; Health Insurance Company or agency; or pharmacy or pharmaceutical company
(IF “YES” TO ANY OF THE ABOVE, THANK AND TERMINATE)
Are you of Ashkenazi Jewish descent, that is are you descended from Central or Eastern European Jews?
_____ Yes (RECORD AND CONTINUE)
_____ No or Doesn’t Know (THANK AND TERMINATE)
How would you best describe yourself as a Jewish person [read both options below]:
_____ “Practicing” or “Religious” [If participant asks for clarification: “regularly attend Jewish religious services at a synagogue, temple, minyan (MIN-yin) or Havurah (hah-vu-RAH)”]
_____ “Cultural”, “Non-Practicing”, or “Non-Religious”
(RECRUIT A MIX; RECRUIT AT LEAST 3 PRACTICING/RELIGIOUS IN EACH GROUP)
Have you ever been diagnosed by a doctor with breast cancer or ovarian cancer?
_____ Yes (THANK AND TERMINATE)
_____ NO (RECORD AND CONTINUE)
Have you ever undergone genetic counseling with a licensed genetic counselor regarding cancer-related concerns? This does not include a conversation with a doctor or nurse.
_____ Yes (THANK AND TERMINATE)
_____ NO (RECORD AND CONTINUE)
Have you ever undergone genetic testing related to cancer or your risk for developing cancer (such as testing for a BRCA1 or BRCA2 gene mutation)?
_____ Yes (THANK AND TERMINATE)
_____ NO (RECORD AND CONTINUE)
What is the highest level of education you have completed?
(RECRUIT A MIX; AT LEAST HALF MUST HAVE SOME COLLEGE OR MORE)
01 High School Diploma or less (RECORD; RECRUIT A MIX; CONTINUE)
02 Some college or associates degree (RECORD; RECRUIT A MIX; CONTINUE)
03 College degree (RECORD; RECRUIT A MIX; CONTINUE)
04 Master’s degree (RECORD; RECRUIT A MIX; CONTINUE)
05 JD or PhD (RECORD, RECRUIT A MIX; LIMIT 1 PER GROUP; CONTINUE)
What is your marital status?
______Currently married or in a legal/state registered domestic partnership
______ Not Married (may include divorced, widowed, separated, and never married)
(RECORD; RECRUIT A MIX OF MARRIED/NOT MARRIED; CONTINUE)
Do you have children?
_____ Yes (RECORD AND CONTINUE)
If so, record how many children, their sexes, and ages: ________________________
_____ NO (RECORD AND CONTINUE)
(RECORD; RECRUIT A MIX OF MOTHERS/NOT MOTHERS; CONTINUE)
What is your estimated annual household income? (RECORD; RECRUIT A MIX)
_____ $25,000 or less
_____ Between $25,000 - $49,000
_____ Between $50,000 - $100,000
_____ More than $100,000
ASSESS AND VERIFY ABILITY TO SPEAK AND UNDERSTAND ENGLISH
Those are all of my questions. You qualify and we would like to invite you to participate in a focus group. The discussion will last about 2 hours and will be audio and video recorded. In appreciation for your time, you will be given $75 after completing the focus group. It’s important to know that none of the information you provide us during the focus group will ever be linked to your name in any way.
Are you willing to participate?
_____ Yes (CONTINUE)
_____ NO (THANK AND TERMINATE, ASK IF THEY CAN SUGGEST A PEER THAT MAY BE INTERESTED)
Groups are scheduled for the following times (INSERT DATES AND TIMES – OFFER AT LEAST ONE EVENING GROUP), which of these works with your calendar?
Prior to the start of the focus group, you will receive information for the focus group. If after we hang up, if you have a question about the focus group or decide you can’t participate, please contact me at___________________.
Now, can you please tell me the following information about yourself?
Name________________________________________________________________________
Mailing Address (include zip code) _____________________________________________________________________________
Email Address__________________________________________________________________
Day Number_________________________ Evening Number____________________________
Mobile Phone (if available) ______________________ Fax (if available) __________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Jennifer Reynolds |
| File Modified | 0000-00-00 |
| File Created | 2021-01-27 |