Act Early Parent Focus Screener

Attachment 5 Act Early Parent Focus Group Screener Form Approved

OMB NO. 0920-XXXX

Exp. Date: xx/xx/xxxx

Attachment 5

Act Early Parent Focus Group Screener

[USE THE FOLLOWING TEXT IF ANSWERING CALL FROM POTENTIAL RESPONDENT:] Thank you for calling about the Children’s Health Project and for your interest in participating in the focus group for parents. In order to see if you’re eligible to participate, we just need to ask you a few questions. It should take no more than 5 minutes.

[USE THE FOLLOWING TEXT WHEN RETURNING A CALL FROM A POTENTIAL RESPONDENT:] I’m [NAME], calling from Westat. You called us recently and left a message about participating in a focus group as part of the Children’s Health Project. Thank you for your call. I have just a few questions for you to see if you’re eligible to participate. It should take no more than 5 minutes.

1. First, how old are you?

• IF 18-55 → CONTINUE

• IF <18 or >55 →THANK AND END [INELIGIBLE]

2. Are you the parent or guardian of a child?

• IF YES → CONTINUE

• IF NO →THANK AND END [INELIGIBLE]

3. How many children do you have?

ENTER NUMBER: __________

(IF >0, GO TO Q4, ELSE THANK AND END [INELIGIBLE])

4. How old [is your child/are your children]?

CHILD 1: __________

CHILD 2: __________

CHILD 3: __________

CHILD 4: __________

CHILD 5: __________

CHILD 6: __________

CHILD 7: __________

(IF ANY CHILDREN ARE AGES 5 OR YOUNGER, GO TO Q5, ELSE THANK AND END [INELIGIBLE])

5. Do you have a child who has been diagnosed with a developmental delay or developmental disability (e.g., ADHD, Autism, Cerebral Palsy, hearing loss, vision impairment, speech or language delay, intellectual or learning disability)?

• IF YES → THANK AND END [INELIGIBLE]

• IF NO → CONTINUE

6. Have you ever worked in the health or medical field (e.g., as a nurse, physician or medical assistant)?

• IF YES → THANK AND END [INELIGIBLE]

• IF NO → CONTINUE

7. Do you work in a clinic, hospital, or doctor’s office?

• IF YES → THANK AND END [INELIGIBLE]

• IF NO → CONTINUE

8. Do you work with children who have special needs or in special education?

• IF YES → THANK AND END [INELIGIBLE]

• IF NO → CONTINUE

9. Have you received the book, Amazing Me. It’s Busy Being 3! from your child’s doctor’s office or any place else?

• IF YES → THANK AND END [INELIGIBLE]

• IF NO → CONTINUE

10. What is the highest level of education you have completed?

• Less than high school

• High school diploma or GED

• Technical college/Associates degree

• Some college

• College degree

• Graduate degree

11. Are you of Hispanic or Latino origin?

• Yes

• No

12. How would you describe your race? (Select all that apply.)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

• Refused

13. Which best describes your total household income?

• Less than $15,000

• $15,000 to $24,999

• $25,000 to $34,999

• $35,000 to $50,000

• Over $50,000→ THANK AND END [INELIGIBLE]

[ELIGIBLE RESPONDENTS:] Thank you for answering those questions. You are eligible to participate in the study. Let me tell you the dates, times, and locations for our upcoming focus groups, so that we can find a time that works for you. [PROCEED TO SCHEDULING]

[INELIGIBLE RESPONDENT TERMINATION:] Thank you for answering those questions. Unfortunately you’re not eligible to participate in our study, but we appreciate your interest and your time today. Goodbye.

Public reporting burden of this collection of information is estimated to average 5 minutes, 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:  OMB (0920-XXXX)