Focus Group Testing to Effectively Plan and Tailor "Bring Your Brave" Communication Campaign Messages

Form Approved

OMB No. 0920-0800

Exp. Date 12/31/2017

Attachment C4:

Screening Instrument for

African-American or

Black Families

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: Referred Relatives (Female Family Members)

[To be used if a primary recruit refers relatives who call into the recruiting service]

Thank you for calling _______________ a professional market research firm. I am not selling anything. We’re currently conducting focus groups for the Centers for Disease Control and Prevention. We want to gather a group of family members for discussion purposes.

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]

1. What is the name of the individual who referred you for this study?

(RECORD; ENSURE MATCHES WITH A KNOWN PRIMARY RECRUIT; CONTINUE)

2. Document gender. [ASK IF UNSURE]

_____ Female (CONTINUE)

_____ Male (THANK AND TERMINATE)

3. How old are you? [READ RANGES]

_____ 17 years old or younger (THANK AND TERMINATE)

_____ 18+ (RECORD; CONTINUE) (at least 2 members of the group need to be 18-44)

4. 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 WHICH SIDE OF THE FAMILY; CONTINUE)

_____ NO (THANK AND TERMINATE)

5. 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; genetic testing company or research institution; health insurance company or agency; or pharmacy or pharmaceutical company

(IF “YES” TO ANY OF THE ABOVE, THANK AND TERMINATE)

6. Have you ever been diagnosed by a doctor with breast cancer or ovarian cancer?

_____ Yes (THANK AND TERMINATE)

_____ NO (RECORD AND CONTINUE)

7. Have you ever had genetic counseling or genetic testing with a licensed genetic counselor or other genetic expert for cancer-related concerns? This does not include a conversation with a doctor or nurse.

_____ Yes (RECORD AND CONTINUE; NOTE SEPARATELY IF RESPONDENT HAS UNDERGONE COUNSELING AND/OR TESTING)

_____ NO (RECORD AND CONTINUE)

8. Do any of the following categories describe your race? If so, which ones? (RECORD AND CONTINUE)

   1. White/Caucasian

   2. Hispanic/Latina

   3. African-American or black

   4. Asian

   5. Ashkenazi Jewish

   6. Biracial

   7. I don’t know/I don't identify with any of these/refuses to answer

9. Are there any other ways you describe your race or ethnicity?

_____ (RECORD AND CONTINUE)

10. What is the highest level of education you have completed? (RECORD AND CONTINUE)

01 High School Diploma or less

02 Some college or associates degree

03 College degree

04 Master’s degree

05 JD or PhD

11. What is your marital status? (RECORD AND CONTINUE)

______Currently married or in a legal/state registered domestic partnership

______ Not Married (may include divorced, widowed, separated, and never married)

12. Do you have children? (RECORD AND CONTINUE)

_____ Yes; record how many children, their sexes, and ages: ____________________

_____ NO

13. What is your estimated annual household income?

_____ $25,000 or less

_____ Between $25,000 - $49,000

_____ Between $50,000 - $100,000

_____ More than $100,000

How many people live in your household? (RECORD)

ASSESS AND VERIFY ABILITY TO SPEAK AND UNDERSTAND ENGLISH

Those are all of my questions. For the focus group to happen, we will need 3-4 of your blood relatives to agree to participate at the same time. Just like what you did in this conversation, other family members will need to call in to answer a few questions and confirm a time that will work for all of you to participate together.

The discussion will last about an hour and a half and will be audio and video recorded. In appreciation for your time, you will each 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 with your family members?

_____ Yes (CONTINUE)

_____ NO (THANK AND TERMINATE, ASK IF THEY CAN SUGGEST A PEER THAT MAY BE INTERESTED)

Groups are scheduled for the following dates (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___________________. 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) __________________