Form 4 Survey 2 Claimant Screener

OMB
 No.:
 0925-­‐XXXX

Expiration
 Date:
 XX/XX/2017

Survey
 2
 –Screener

S1.

Hello,
 may
 I
 speak
 with
 (CLAIMANT
 (IF
 NEEDED:
 I
 am
 trying
 to
 reach
 the
 person
 who
 recently

received
 a
 letter
 from
 the
 Social
 Security
 Administration
 about
 a
 research
 study))?

[IF
 ASKED,
 “WHO’S
 CALLING?”]:

My
 name
 is
 (DATA
 COLLECTOR)
 and
 I
 am
 calling
 from
 Westat
 about
 a
 Social
 Security

Administration
 research
 study.

YES/SPEAKING
 .................................

 1
  (GO
 TO
 INTRO1)

NOT
 AVAILABLE
 ...............................

 2
  (SET
 CALLBACK)

OTHER
 (FINAL)
 ................................

 3
  (GO
 TO
 THANK1
 AND
 RECORD
 FINAL
 TRC
 STATUS
 CODE)

NEW
 PHONE
 NUMBER
 ....................

 4
  (RECORD
 NEW
 PHONE
 NUMBER)

[INTRO1]

Hello,
 this
 is
 (INTERVIEWER)
 and
 I’m
 calling
 from
 Westat
 about
 a
 Social
 Security
 Administration
 (SSA)

research
 study.

 We
 spoke
 to
 you
 about
 a
 week
 ago.

 Thank
 you
 for
 your
 participation
 in
 that
 survey.

We
 are
 calling
 back
 now
 to
 see
 if
 you
 are
 able
 to
 take
 part
 in
 the
 second
 survey.

Before
 we
 get
 started,
 I
 am
 required
 to
 read
 to
 you
 a
 statement
 from
 the
 Office
 of
 Management
 and

Budget
 (the
 OMB).

 This
 statement
 will
 provide
 you
 with
 contact
 information
 should
 you
 have
 questions

or
 comments
 about
 the
 amount
 of
 time
 it
 will
 take
 to
 answer
 the
 next
 few
 questions.

OMB
 No.:
 0925-­‐XXXX

Expiration
 Date:
 XX/XX/2017

Public
  reporting
  burden
  for
  this
 collection
  of
  information
  is
  estimated
 to
 average
  3-­‐15
 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
 aspects
 of
 this
 collection
 of
 information,
 including
 suggestions
 for

reducing
  this
  burden
  to:
  NIH,
  Project
  Clearance
  Branch,
  6705
  Rockledge
  Drive,
  MSC
  7974,
  Bethesda,
  MD
  20892-­‐7974,

ATTN:
 PRA
 (0925-­‐XXXX).

I
 appreciate
 for
 your
 patience
 as
 I
 read
 that.

S2.

Now,
 I
 need
 to
 ask
 a
 couple
 questions
 to
 make
 sure
 I
 am
 speaking
 to
 the
 correct
 person.

 When

we
 spoke
 to
 you
 a
 little
 over
 a
 week
 ago,
 please
 tell
 me
 if
 you
 took
 that
 survey
 with
 an

interviewer
 over
 the
 telephone
 or
 on
 the
 internet
 by
 yourself.

[INTERVIEWER:
 CHECK
 CLAIMANT’S
 RESPONSE
 AT
 S2
 WITH
 THE
 NOTES
 IN
 THE
 CLAIMANT’S

SCREENING
 HISTORY
 BOX
 AT
 THE
 TOP
 RIGHT
 OF
 THE
 SCREEN].

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ACCURATE
 RESPONSE
 .................................................................
 1
 (GO
 TO
 INTRO2)

INACCCURATE
 RESPONSE
 ..........................................................
 2
 (GO
 TO
 S3)

REFUSE
 ........................................................................................
 7
 (GO
 TO
 S3)

DON’T
 KNOW/DON’T
 REMEMBER
 ..............................................
 8
 (GO
 TO
 S3)

S3.

Please
 confirm
 your
 date
 of
 birth?

[INTERVIEWER:
 CHECK
 CLAIMANT’S
 RESPONSEAT
 S3
 WITH
 THE
 DATE
 OF
 BIRTH
 LISTED
 AT
 THE

TOP
 OF
 THE
 SCREEN].

ACCURATE
 RESPONSE
 .................................................................
 1
 (GO
 TO
 INTRO2)

INACCCURATE
 RESPONSE
 ..........................................................
 2
 (GO
 TO
 THANK1)

REFUSE
 ........................................................................................
 7
 (GO
 TO
 THANK1)

DON’T
 KNOW/DON’T
 REMEMBER
 ..............................................
 8
 (GO
 TO
 THANK1)

[INTRO2]

Thank
 you
 for
 that
 information.

 I
 am
 calling
 today
 to
 invite
 you
 to
 participate
 in
 the
 second
 survey
 as

part
 of
 the
 SSA
 Functional
 Assessment
 Study.

 This
 survey
 is
 very
 similar
 to
 the
 first
 one.

 It
 will
 take

about
 45
 minutes
 to
 complete.

 After
 you
 complete
 the
 survey,
 you
 will
 receive
 a
 check
 for
 $30
 for
 your

time.

S4.

Do
 you
 wish
 to
 continue
 with
 the
 study?

YES
 .........................................................................
 1
 (GO
 TO
 S5)

NO
 .........................................................................
 2
 (GO
 TO
 THANK1)

S5.

You
 have
 the
 option
 of
 doing
 the
 survey
 now
 over
 the
 telephone
 or
 I
 can
 schedule
 the
 interview

for
 a
 different
 time.

 You
 can
 also
 go
 on
 the
 Internet
 to
 complete
 the
 survey
 on
 your
 own.
 Which

would
 you
 prefer?

INTERNET
 ..............................................

  1
  (GO
 TO
 S6)

TELEPHONE
 NOW
 ..................................

  2
  (GO
 TO
 WEB
 SURVEY)

TELEPHONE
 LATER
 ................................

  2
  (GO
 TO
 APPT
 SCREEN;
 THEN
 THANK2)

S6.

We
 will
 send
 you
 an
 email
 with
 details
 and
 instructions
 for
 logging
 on
 to
 the
 web
 survey.
 May
 I

please
 have
 your
 email
 address?

[NOTE
 TO
 INTERVIEWER,
 RESPONDENT
 CAN
 NOT
 DO
 SURVEY
 ON
 INTERNET
 IF
 THEY
 DO
 NOT

HAVE
 AN
 EMAIL
 ADDRESS
 OR
 REFUSE
 TO
 PROVIDE
 AN
 EMAIL
 ADDRESS
 FOR
 US
 TO
 SEND
 THE

SURVEY
 LINK.]

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THANK1.

THANK2.

THANK3.

E-­‐MAIL
 ADDRESS
 ____________________________

CONFIRM
 E-­‐MAIL
 ADDRESS
 ____________________

(GO
 TO
 THANK3)

Thank
 you,
 but
 those
 are
 all
 the
 questions
 I
 have
 for
 you.
 Good-­‐bye.

Thank
 you
 for
 taking
 the
 time
 to
 answer
 these
 questions.
 We
 look
 forward
 to
 your

participation
 in
 our
 study.

Thank
 you
 for
 taking
 the
 time
 to
 answer
 these
 questions.
 You
 should
 receive
 an
 email

with
 a
 link
 for
 the
 web
 survey
 soon.
 We
 look
 forward
 to
 your
 participation
 in
 our
 study.

3

Version
 6

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