Recruitment Form -Low SES

Form Approved

OMB No. 0920-0800
Expiration Date: 12/31/2017

CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC)

Focus Groups Assessing the Uptake and Effectiveness of Inside Knowledge: Get the Facts About Gynecologic Cancer Campaign Materials

Respondent Recruitment Form

GROUP DATE/TIME:_________________________________________________________

Name:________________________________________________________________________

Phone # +/or e-mail address for confirmation: ______________________________________

_______________________________________________________________________________

Address:

City, State: _____________________________________ZIP Code:

Public reporting burden for this collection of information is estimated to average 2 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).

Hello, my name is __ I’m with _______, (insert National Comprehensive Cancer Program name). On behalf of the federal Centers for Disease Control and Prevention, we are planning a focus group study with the public about gynecologic cancers. Some people we speak with today will be invited to participate for about 2 hours of your time. To show appreciation you will receive a $25 gift card to local grocery store or coffee shop.

May I ask you a few questions?

1. Are you a woman 18 years of age or older?

1 No 2 Yes

2. Do any of the following apply to you?

Household income less than $35,000

Less than a High School Diploma or GEB

Uninsured

Unemployed

Make only minimum wage

1 No 2 Yes

If yes to 1 and 2 then go to INVITATION:

3. INVITATION:

Thank you. We are convening focus groups with the public to discuss gynecologic cancers. I hope you will be interested in participating. The focus group will take place nearby.

We would like to invite you to be in a group on... [insert schedule specifics]

Are you available?

1. No [Thank and end call.] 2 Yes

If yes, then

Great…I will send you information with directions.

If no to question 1or question 2, then go to INELIGIBLE:

Unfortunately you are not eligible to participate in these focus groups. Thank you so much for your time.

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