Parent Screener

Attachment C

Parent Screener

Form Approved

OMB No. 0920-0572

Expiration Date: 2/28/2015

Public Reporting burden of this collection of information is estimated at 10 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 NW, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-0572).

Screener/Parents of Teens (English)

CDC “Parents are the Key” Toolkit Materials Evaluation

10-MINUTE ASSESSMENT TO RECRUIT FOR ONLINE FOCUS GROUPS

(INTRO) We would like to invite you to participate in an online group discussion, also called a focus group, [INSERT DATE]. The group session will last for approximately 90 minutes and will be conducted in English.

The session is being sponsored by the Centers for Disease Control and Prevention and is focused on a communications campaign about safe teen driving. The campaign highlights the message that motor vehicle crashes are the leading cause of death among teens, but there are proven steps that parents can take to help keep teens safer on the road. 

To express our appreciation for assisting us with your insights, we will offer a gift for participation of $30 in equivalent reward points. But, first I'd like to ask you a few questions for background information to see if you qualify for this project. [TYPE: Static]

(RECRUIT1) Would you be available to participate in an online focus group on the day/time listed below? [TYPE: Multiple Choice]

1:	Yes, I would like to participate on [INSERT DATE & TIME]
2:	No [TERMINATE]

(S1. DEMOGRAPHICS ETHNICITY) Which of the following best describes your ethnicity? [TYPE: Multiple Choice]

1: Hispanic or Latino

2: Not Hispanic or Latino

(S2. DEMOGRAPHICS RACE) Select one or more of the following options to describe your race. [TYPE: Multiple Choice]

1: American Indian or Alaska Native

2: Asian

3: Black or African American

4: Native Hawaiian or Other Pacific Islander

5: White

(S3. DEMOGRAPHICS GENDER) What is your gender? [TYPE: Multiple Choice]

1:	Male
2:	Female

(S4. DEMOGRAPHICS AGE) Which of the following includes your age? [TYPE: Multiple Choice]

1:	Under 18 years old [TERMINATE]
2:	18 to 24 years old [TERMINATE]
3:	25 to 29 years old [TERMINATE]
4:	30 to 34 years old
5:	35 to 39 years old
6:	40 to 44 years old
7:	45 to 49 years old
8:	50 to 54 years old
9:	55 to 59 years old
10:	60 to 64 years old
11:	65 to 69 years old
12:	70 years of age and older [TERMINATE]

(S5. DEMOGRAPHICS STATE) In which state do you live? [TYPE: Multiple Choice]

1:	Alabama
2:	Alaska
3:	Arizona
4:	Arkansas
5:	California
6:	Colorado
7:	Connecticut
8:	Delaware
9:	District of Columbia
10:	Florida
11:	Georgia
12:	Hawaii
13:	Idaho
14:	Illinois
15:	Indiana
16:	Iowa
17:	Kansas
18:	Kentucky
19:	Louisiana
20:	Maine
21:	Maryland
22:	Massachusetts
23:	Michigan
24:	Minnesota
25:	Mississippi
26:	Missouri
27:	Montana
28:	Nebraska
29:	Nevada
30:	New Hampshire
31:	New Jersey
32:	New Mexico
33:	New York
34:	North Carolina
35:	North Dakota
36:	Ohio
37:	Oklahoma
38:	Oregon
39:	Pennsylvania
40:	Rhode Island
41:	South Carolina
42:	South Dakota
43:	Tennessee
44:	Texas
45:	Utah
46:	Vermont
47:	Virginia
48:	Washington
49:	West Virginia
50:	Wisconsin
51:	Wyoming

(S6. DEMOGRAPHICS TEENS) Please indicate the ages of any of your children currently living in your household. Please select all that apply. [TYPE: Multiple Choice]

1:	Under age 12 [TERMINATE]
2:	Age 13
3:	Age 14
4:	Age 15
5:	Age 16
6:	Age 17
7:	Age 18
8:	Over age 18 [TERMINATE]
9:	No children living in household [TERMINATE]

(S7a. DEMOGRAPHICS TEENS) Please indicate the gender(s) of your child(ren) between the ages of 13-18? Please select all that apply. For instance, if you have a boy(s) and a girl(s), then select both male and female below.

1:	Male
2:	Female

(S7b. TEEN DRIVER)

Which of the following best describes the teen(s) in your household? Please select all that apply.

[TYPE: Multiple Choice]

1:	At least 1 teen in my household currently has a driver's license
2:	At least 1 teen in my household will obtain a driver's license in the next 3-5 years
3:	NO teen(s) in my household has plans to obtain a driver's license in the next 3-5 years [TERMINATE]

(S8. DEMOGRAPHICS EDUCATION) Which one of the following best describes your highest educational attainment? [TYPE: Multiple Choice]

1:	High school graduate or less
2:	Some college, no degree
3:	Undergraduate degree
4:	Graduate degree
5:	Something else
6:	Prefer not to answer

(S9. DEMOGRAPHICS INCOME) Please indicate which of the following categories includes your household income: [TYPE: Multiple Choice]

1:	Less than $25,000 a year
2:	$25,000 but less than $50,000
3:	$50,000 but less than $75,000
4:	$75,000 but less than $100,000
5:	$100,000 but less than $125,000
6:	$125,000 but less than $150,000
7:	$150,000 but less than $175,000
8:	$175,000 but less than $200,000
9:	$200,000 or more
10:	Prefer not to answer

(FLASH CHECK) You will need to have the Flash player installed on your system in order to join the live session.

Please click here to make sure you have Flash.

If you do not, then follow the instructions to install Flash and return to this page. If you do, then select 'Yes' below and click the Next button. [TYPE: Multiple Choice]

1:	Yes, I have Flash!
2:	No [TERMINATE]

(CONNECTION CHECK) What type of internet connection do you currently have on the computer you will be using to participate in the online discussion session? [TYPE: Multiple Choice]

1:	Dial-up connection [TERMINATE]
2:	Broadband connection (e.g., cable, DSL, Fios, etc.)

(THURS RECRUIT) Congratulations! You have agreed to participate in a live online session on ...

[INSERT DATE & TIME]

 

• Prior to the session, you will receive an email confirmation from 'Stratalys Research' with a link and instructions for logging into the session.

• You may log in up to 20 minutes before the start time of the session. You will not be allowed into the session if you log in late.

• You may participate from any desktop or laptop computer.

• NOTE: Please make sure you can devote the entire 90 minutes to the session. You must complete the entire session in order to receive your reward. Also, please try to ensure that you are able to focus on the session by eliminating any distractions.

Please confirm that you will be participating by selecting 'Yes' below ...

 [TYPE: Multiple Choice]

1:	Yes, I'll be participating
2:	No [TERMINATE]

(DEMOGRAPHICS EMAIL) Please enter your email address in the box below so that we can send you your login information for the group session. We will ONLY use your email to send you this one additional message with your login information. Your email will NOT be used for ANY OTHER PURPOSES. (DOUBLE CHECK your email address carefully to make sure you typed it correctly!) [TYPE: Open End]

(S9. DEMOGRAPHICS MARITAL) Please indicate your marital status. [TYPE: Multiple Choice]

1:	Married
2:	Living with a partner
3:	Widowed
4:	Divorced
5:	Separated
6:	Never been married
7:	Prefer not to answer

(S10. DEMOGRAPHICS EMPLOYMENT) Are you currently employed, unemployed and looking for work, or retired? [TYPE: Multiple Choice]

1:	Employed (full-time)
2:	Employed (part-time)
3:	Unemployed
4:	Homemaker
5:	Student
6:	Retired

(COMPLETE) Thank you for completing the online focus group registration! You will receive an email with login information on the day of the session. We look forward to your participation. Please click on the link below to submit your answers ...

[TYPE: Static]

(OVERQUOTA) Thank you for participating! We needed a specific number of people to take part in the discussion session, and we have already exceeded that number! Although we have reached our limit for the group session, we appreciate your time.

Please click on the link below to submit your answers ...
[TYPE: Static]

(TERMINATE) Thank you for participating! Although you did not qualify for this study, we appreciate your time. Thanks again!

Please click on the link below to submit your answers ...
[TYPE: Static]

PLEASE RECRUIT FOR MIX OF RACE, GENDER AND AGE OF PARENTS AND GENDER AND AGE OF TEEN CHILDREN

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www.stratalys.com