OMB No. 0920-0800
Exp. Date: 12/31/2017
Focus Group Testing for the Screen for Life: National Colorectal Cancer Action Campaign.
Screening and Recruitment Form
GROUP DATE/TIME:_______________________________________________ Name:_____________________________________________________________ Phone # +/or e-mail address for confirmation: ___________________________ ___________________________________________________________________ Address: City, State: _____________________________________ZIP Code:
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Public reporting burden for 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0800).
Ask to speak to an adult male or female living in the household:
Hello, my name is . I’m with , a local opinion research company. Today, we are working on a study for the Centers for Disease Control and Prevention -- or CDC -- to learn about people’s attitudes and beliefs about health. I want to assure you that this is not a sales call. In fact, some of the people I talk with today will be invited to participate in a focus group and will receive a token of appreciation of $75 for about two hours of time. May I ask you a few questions?
NOTE: Please listen carefully to make sure that anyone recruited can speak clearly and loudly enough to participate fully in a group discussion.
1. Record respondent gender:
1 Male [Recruit a mix; must have both in all groups.]
Female
2. For this study, we need to know your age. What is your age? [Put age here: _______]
Do not read. Fill in age respondent gives you. Then circle category it’s in.
1 Under 45 years old [Terminate]
2 45 - 49 years old (Continue; OK 1-2 only]
3 50 - 54 years old [Continue]
4 55 - 59 years old [Continue]
5 60 - 64 years old [Continue]
6 65 - 72 years old [Continue]
7 73 or older [Terminate]
3. Are you currently employed? [CONTINUE for all -- Recruit a mix]
1 No
2 Yes, part time
3 Yes, full time
(If yes...) What type of work do you do? ____________________________________
(Terminate health professional – e.g. doctor, nurse, physician assistant, or nurse practitioner; otherwise, information only)
4. Have you or your spouse ever worked or volunteered for any of the following types of organizations?
Doctor’s office, hospital, clinic, pharmaceutical or drug company
If yes:
Please find out what type(s) of paid or volunteer positions and whether position was held by respondent and/or spouse: ________________________________________________________________________
[TERMINATE if prospective participant is obviously a health professional such as doctor or nurse. Otherwise, continue screening. If unsure, check with client before recruiting.]
Terminate if any of the following are mentioned:
Health department or community health agency (okay, if not a doctor or nurse)
Marketing research, advertising, or public relations agency or department
Centers for Disease Control and Prevention (“C-D-C”) or the National Institutes of Health (“N-I-H”)
An organization that focuses on cancer such as the American Cancer Society or another cancer-related organization
5a. How would you describe your ethnicity?
1 Hispanic, Latino/Latina [Skip to Q5b]
NOT Hispanic or Latino (Fill in here: ________________________________)
5b. What is your race? I am going to read a list. You can select one or more options from the list. Do you consider yourself …
RECORD ALL ANSWERS GIVEN BY RESPONDENT, BUT DO NOT PROBE FURTHER. OPTION #6, “OTHER,” MAY BE USED AS A RECORDING OPTION FOR NON-CONFORMING RESPONSES. OPTION #6 SHOULD NOT BE PRESENTED AS A RESPONSE OPTION.
{ONE OR MORE CATEGORIES MAY BE SELECTED}
1. White [Recruit @4-5]
2. Black or African American [Recruit @4-5]
[For responses 3-6, OK to recruit up to 4, with adjustments for California]
3. American Indian or Alaska Native
4. Asian
5. Native Hawaiian or Other Pacific Islander
6. OTHER
6. Do you have any kind of health insurance to pay for routine health care? [Information only, ]
1 Yes
If yes: What is the name of your insurance plan or plans: __________________
2 No
3 Don’t know
7. When was your last routine check-up or physical? ______________ [Information only]
8. Have you ever been told by a doctor that you have [READ SLOWLY] a bowel or intestinal condition, such as colitis, inflammatory bowel disease, Crohn’s disease, colon cancer, or polyps in the colon or rectum? (POLYPS ARE SMALL GROWTHS IN YOUR COLON OR RECTUM.)
1 Yes: Which of these have you been told you have? ________________[Terminate]
2 No [Continue]
3 Not sure/don’t know [Continue]
9A. Have you ever been diagnosed with any kind of cancer?
1 No [Continue; go to Q11]
2 Not sure/don’t know [Continue; go to Q11]
If response is LESS than 5 years, terminate. [Save all terminates]
If response is MORE than 5 years, recruit up to 3 who otherwise qualify.
9B. [Read slowly…] Have you…OR your mother…father…brother…sister…or any of your
children ever had colon cancer?
1 Yes [Terminate]
2 No [Continue]
3 Not sure/don’t know [Continue]
Note: OK if more distant blood relative, such as uncle, aunt, grandparent, cousin, etc.
10. Thinking about the doctor visits you have had in the last 5 years, have you been tested for:
1 Colon cancer
Yes Continue
No Continue
Don’t know Continue
2 [Ask Females only] Breast cancer Yes No [Information Only]
3 [Ask Males only] Prostate cancer Yes No [Information Only]
Now I am going to ask you some questions to see if you have had particular medical tests. I am used to talking with people about these tests, and I hope that you will not feel uncomfortable about these questions.
11a. There is a test that checks for blood in your stool – this is a kit you use at home to collect one or more stool samples from the toilet, and put them on a card that you send back to the doctor or a lab to be checked.
Have you ever been given a test kit to check for blood in your stool?
3 Yes If yes:
Did you complete the test and return the card to the lab or doctor?
1 No [Continue; go to 11b]
2 Don’t remember [Continue; go to 11b]
3 Yes If yes:
When was the last time you completed this test?
[Record answer____________________] Note:
If unknown, try to jog memory by asking: Approximately when? [Read]
1 Within 1 year or approximately a year ago [ASK Qs in BOX; then terminate]
2 More than a year ago, but less than 2 years ago [ASK Qs in BOX; then terminate]
IF PERSON TERMINATES HERE, ASK:
T1. I am going to read several reasons people say they did this test. For each one, please tell me whether or not it applied to you the FIRST time you did the test. (Circle responses)
a. My doctor recommended it. YES, applied to me NO
b. My spouse or partner convinced me that it was important. YES, applied to me NO
c. A friend convinced me that it was important. YES, applied to me NO
d. I saw an ad recommending it. YES, applied to me NO
e. Any other reason? (If yes, ask for reason) _________________________________
T2. What was the #1 MOST important reason for you: ______________________________
T3. Have you ever had a colonoscopy. It is a test in which a long, flexible, lighted tube is inserted into your rectum. Typically you are given IV medication to relax and you must have someone else drive you home.?
YES NO DON’T REMEMBER
T4. Do you know what disease or condition a colonoscopy is used to find? [Information Only] Yes (List all):________________________________________________________________ No Not sure
T5. If a relative or friend of yours asked you about whether they should be tested for colon cancer, what would you say to encourage him or her to get tested? ___________________________________________________________________________
THANK AND END |
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3 At least 2 or more years ago [Continue with Q11b. below]
11b. Now I am going to ask you some questions about a medical test called a colonoscopy. During this test, a doctor inserts a flexible, lighted tube into your rectum to view the colon. You are usually given medication through an IV to relax, and you must have someone else drive you home. Some people confuse this test with another test in which a tube is inserted through the mouth or the nose. That’s a different test.
Have ever had a colonoscopy? .
No [Continue; go to 11c]
2 Yes [Continue with Q right below about when colonoscopy was done]
3 Not sure [Continue; go to 11c]
Approximately, when was the last time you had a colonoscopy?
[Record answer]________________________
If response is…
a. Within the last year [ASK Qs in BOX; then Terminate]
b. Within the last 2-3 years [ASK Qs in BOX; then Terminate]
c. Within the last 4-5 years [ASK Qs in BOX; then Terminate]
[Continue with Q below about when completed to see if this jogs person’s memory]
IF ANSWERS a, b, or c, ASK:
T7. I am going to read several reasons people say they had a colonoscopy. For each one, please tell me whether or not it applied to you the FIRST time you had a colonoscopy. (Circle responses)
a. My doctor recommended it. YES, applied to me NO
b. My spouse or partner convinced me that it was important. YES, applied to me NO
c. A friend convinced me that it was important. YES, applied to me NO
d. I saw an ad recommending it. YES, applied to me NO
e. Any other reason? (If yes, ask for reason) _____________ ____________________
T8. What was the #1 MOST important reason for you: ______________________________
T9. If a relative or friend of yours asked you about whether they should be tested for colon cancer, what would you say to encourage him or her to go? ___________________________________________________________________________
THANK AND TERMINATE FOR THOSE WHO ANSWER a, b, or c. |
d. 5 or more years ago, but less than 10 years
[Terminate; save these terminates.]
e. More than 10 years ago [Continue]
f. Don’t know/don’t remember If still unknown, try asking…Was it:
Within the last 2 years [Terminate; end]
Within the last 5 years [Terminate; end]
5 or more years ago, but less than 10 years [Terminate; save these]
Longer than 10 years ago [Continue]
11c. You may have heard about a test called a “virtual colonoscopy” or “CT colonoscopy.” This test is usually done in the radiology department of a hospital or clinic. For this test, you will be asked to lie on a table, and a thin tube is inserted into the rectum. Images of the large intestine are then taken with an MRI or a CT machine. A virtual colonoscopy does not require medication, and you are awake during the test. The test usually takes about 10 minutes.
Do you recall whether you have ever had a virtual colonoscopy? .
No [Continue; go to 11c]
2 Yes [Continue with Q right below about when virtual colonoscopy was done]
3 Not sure [Continue with Q below about when completed to see if this
jogs person’s memory]
Approximately, when was the last time you had a virtual colonoscopy?
[Record answer]________________________
If response is…
a. Within the last year [ASK Qs in BOX; then Terminate]
b. Within the last 2-3 years [ASK Qs in BOX; then Terminate]
c. Within the last 4-5 years [ASK Qs in BOX; then Terminate]
IF ANSWERS a, b, or c, ASK:
T7. I am going to read several reasons people say they had a virtual colonoscopy. For each one, please tell me whether or not it applied to you the FIRST time you had a virtual colonoscopy. (Circle responses)
a. My doctor recommended it. YES, applied to me NO
b. My spouse or partner convinced me that it was important. YES, applied to me NO
c. A friend convinced me that it was important. YES, applied to me NO
d. I saw an ad recommending it. YES, applied to me NO
e. Any other reason? (If yes, ask for reason) _____________ ____________________
T8. What was the #1 MOST important reason for you: ______________________________
T9. If a relative or friend of yours asked you about whether they should be tested for colon cancer, what would you say to encourage him or her to go? ___________________________________________________________________________
THANK AND TERMINATE FOR THOSE WHO ANSWER a, b, or c. |
d. 5 or more years ago, but less than 10 years
[Terminate; save these terminates.]
e. Don’t know/don’t remember If still unknown, try asking…Was it:
Within the last 2 years [Terminate; end]
Within the last 5 years [Terminate; end]
5 or more years ago, but less than 10 years [Terminate; save these]
11d. Now I’m going to ask you about a test called a sigmoidoscopy. During this test, a doctor inserts a flexible, lighted tube into your rectum to view the colon. The sigmoidoscopy looks at part of the colon and is usually done without medication in the doctor’s office.
Do you recall whether you have ever had a sigmoidoscopy?
1 No [Continue; go to 11d]
2 Yes [Continue; ask Q below about when test was done]
3 Not sure [Continue; ask Q below about when test might have
been to see if it jogs person’s memory]
Approximately, when was the last time you had a sigmoidoscopy?
Record answer: ____________________
For responses…
Within the last year [Terminate]
Within the last 2-3 years [Terminate]
Within the last 4-5 years [Terminate]
6 or more years ago, but less than 10 [Continue]
More than 10 years [Continue]
Don’t know….Try to jog person’s memory by asking: Approximately when?
[Read] Was it…
Within the last 2 years [Terminate]
Within the last 5 years [Terminate]
6 or more years ago, but less than 10 years [Continue]
More than 10 years ago [Continue]
Thank you for answering all these medical questions. I have just a few more questions but these are not medical.
12. What is the last grade or year of school you completed?
1 Less than high school [recruit no more than 2]
2 Some high school (no more than 2; save screeners for people who terminate here but qualify otherwise.]
Recruit @half who answer 3, 4 or 5
3 Completion of high school
4 Some college
5 Completion of college
Post-graduate degree
[No more than 2 with post graduate degree; save screeners for people who terminate here but qualify otherwise.]
13. Is your total annual household income:
Below $60,000 [Recruit @6]
Above $60,000 [Recruit @6]
How many people live in your household? _______________
[Information only]
14.. When, if ever, was the last time you participated in a focus group?
Have never participated [Continue]
Within the last 6 months: What was the topic? _____________________________
Terminate if topic was cancer-related. SAVE all terminates.
More than 6 months ago [Continue]
INVITATION:
The project I am working on includes several small groups of up to 9 people. They will meet once for about two hours to talk informally and give their opinions about some information that will be used in advertising. The discussion will be at our office which is easy to get to. You do not need to prepare in any way or have any special skills to participate, although there will be some brief reading involved. This truly is about your opinions and reactions to ideas for advertising. Everyone who participates will receive $75 for attending. Light refreshments will be served.
We would like to invite you to participate in a group on [day/date/time]
____________________________________________________
Are you available to participate?
1 Yes [If yes, ask reading comfort question on next page; If OK, record
information on front of screener for confirmation]
2 No [Thank and end call.]
READING COMFORT:
I have one more question…As I mentioned, this part of the study will involve some reading. Some people have vision or reading difficulties that make them prefer to be considered for other studies we may do instead. Will you be able to read some brief materials or would you prefer to be contacted for another study?
____Reading is OK.
REMIND PEOPLE:
to bring reading glasses to alert them that the group will involve reading materials.
that pagers and cell phones cannot be permitted during the group.
Group itself will take about 2 hours, so total time commitment will be slightly longer… important to arrive at least 15 minutes early to check in and have refreshments.
that a place is specially reserved for them so it is very important to call if something comes up so that someone can be invited to take their place.
[Type text]
| File Type | application/msword |
| File Modified | 2015-06-22 |
| File Created | 2015-06-22 |