Form 0920-0572 Attachment 4 Screener_10282014

Audience Research on Self-Management Education Phase III

Attachment 4 to the HMTS Expedited Review Form

Contents

Attachment 4: Eligibility Screener 1

Form Approved

OMB No. 0920-0572

Exp. Date: 2/28/2015

Attachment 4: Eligibility Screener

Audience Research on Self-Management Education Phase III

Public reporting of this collection of information is estimated to average 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 NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Group	Location	Date/Time	Audience
#1	San Antonio, TX	TBA	Women with 1 or more chronic conditions
#2	San Antonio, TX	TBA	Women with 1 or more chronic conditions
#3	San Antonio, TX	TBA	Men with 1 or more chronic conditions
#4	San Antonio, TX	TBA	Men with 1 or more chronic conditions
#5	Cincinnati, OH	TBA	Women with 1 or more chronic conditions
#6	Cincinnati, OH	TBA	Women with 1 or more chronic conditions
#7	Cincinnati, OH	TBA	Men with 1 or more chronic conditions
#8	Cincinnati, OH	TBA	Men with 1 or more chronic conditions

Recruitment:

(For each focus group, recruit 10 for 8 participants to show)

[Request to speak with an adult in the household.]

Hello, I’m _______________. I work for _____________________, an independent research firm. We are doing a study for the Centers for Disease Control and Prevention, also known as the CDC, to find out what people think about some of the materials that they plan to share with the public and to get input regarding messages about programs for ongoing health problems. We are looking for people to take part in discussion groups about these topics. Input and ideas from these discussions will help inform CDC about materials that will be useful to the public. We are not selling any product or service. Everyone who is eligible and participates will receive $50 as a thank you for their time.

I would like to ask you some questions to see if there is a discussion group that you could join. It will take about 5-10 minutes to determine your eligibility to participate in the discussion group. The discussion groups will be held on [Dates] at [Place] and will last about 90 minutes if you choose to participate.

Some of the questions I am about to ask you are about your health. These questions may feel personal and sensitive. You do not have to answer any question if you don’t feel comfortable, and you may stop at any time. Do you have time now to answer a few questions?

May I continue with my questions?

1. [Record gender—ask if unsure]

( ) Female

( ) Male

[Recruit a mix over time]

2. Have you participated in a focus group, intercept interview, telephone survey, and/or online survey in which you were asked your opinions regarding a product, a service, or advertising within the past six months?

( ) Yes <<Terminate

( ) No

3. Do you, or does any member of your household or immediate family work for: [Read each statement below]

( ) a market research company <<Terminate

( ) an advertising agency or public relations firm <<Terminate

( ) the media (TV/radio/newspapers/magazines) <<Terminate

( ) as a healthcare professional (doctor, nurse, pharmacist, dietician, etc.) <<Terminate

Terminate >> If any YES

[Continue only if none of the above employment situations are marked.]

4. In which of the following categories does your age fall:

( ) under 18 years of age <<Terminate

( ) 18-24 years of age <<Terminate

( ) 25-34 years of age <<Terminate

( ) 35-44 years of age <<Terminate

( ) 45-54 years of age

( ) 55-64 years of age

( ) 65-75 years of age

( ) 76 years of age or older <<Terminate

[Only recruit participants who are 45-75 years of age.]

5. Do you consider yourself Hispanic or Latino?

( ) Hispanic or Latino

( ) Not Hispanic or Latino

6. What race or races do you consider yourself to be? (CHOOSE ALL THAT APPLY)?

( ) American Indian or Alaska Native

( ) Asian

( ) Black or African American

( ) Native Hawaiian or Other Pacific Islander

( ) White

[Recruit a mix of Hispanic, White, and African American participants over time (approximately 1/3 Hispanic, 1/3 White, and 1/3 African American. AI/AN, Asian, and NH/PI not critical to recruit]

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

( ) Grade school

( ) Less than high school graduate/some high school

( ) High school graduate or completed GED

( ) Some college or technical school degree

( ) Received four-year college degree

( ) Some post graduate studies

( ) Received advanced degree

( ) Other: _____________________

( ) [Do not read; record only] Refuse <<Terminate

[Recruit a mix of college degree or more and less than college degree. Limit recruitment of some post graduate studies and received advanced degree to no more than 2 individuals per group.]

8. Which of the following categories best describe your total annual household income?

( ) Under $20,000/year

( ) $20,001 - $30,000/year

( ) $30,001 - $40,000/year

( ) $40,001 - $50,000/year

( ) $50,001 - $60,000/year

( ) $60,001 - $80,000/year

( ) $80,001 - $100,000/year

( ) Over $100,000/year

[Recruit a mix in each segment. Limit recruitment of individuals with income over local median income to no more than 3 participants per group.]

Market	San Antonio, TX (Bexar County, TX)	Cincinnati, OH (Hamilton County, OH)
Median Income	$49,141	$49,104
Limit Recruitment of:	>$50,000/year	>$50,000/year

9. Have you EVER been told by a doctor or other health professional that you had…

5a. [Asthma or lung disease, such as asthma or chronic obstructive pulmonary disease (also known as COPD), which includes emphysema and chronic bronchitis]?

( ) Yes

( ) No

( ) [Do not read; record only] Refuse/Don’t Know

5b. [Arthritis]?

( ) Yes

( ) No

( ) [Do not read; record only] Refuse/Don’t Know

5c. [Diabetes]?

( ) Yes

( ) No

( ) [Do not read; record only] Refuse/Don’t Know

5d. [Heart Disease, such as hypertension, congestive heart failure, or coronary artery disease (also known as ischemic heart disease), which includes angina or heart attack]?

( ) Yes

( ) No

( ) [Do not read; record only] Refuse/Don’t Know

5e. [Depression]?

( ) Yes

( ) No

( ) [Do not read; record only] Refuse/Don’t Know

5f. [Cancer]?

( ) Yes

( ) No

( ) [Do not read; record only] Refuse/Don’t Know

[Terminate if “No” or “Refuse/Don’t Know” to all 5a-f. Terminate if “Yes” for 5f and “No” for 5a-e. Recruit a mix of health conditions for each group. Recruit at least 2 (but no more than 6) participants with each chronic condition or ongoing health problem for all groups.]

10. [As appropriate, repeat and record for each chronic condition or ongoing health problem]: For how long have you had [Asthma or lung disease/arthritis/diabetes/heart disease/depression/stroke]?

Asthma or Lung Disease:___ years

Arthritis:___ years

Diabetes:___ years

Heart Disease:___ years

Depression: ___ years

11. [Record number of chronic conditions or ongoing health problems:]

( ) 1 chronic condition or ongoing health problem

( ) More than 1 chronic condition or ongoing health problem

[Recruit a mix in each segment. Recruit at least 3 participants per group with only 1 ongoing health problem and at least 3 participants per group with more than 1 ongoing health problem.]

12. Thinking about your [ongoing health problem or problems], which of the following best describes you TODAY?

( ) I can do everything I want to do. <<Terminate

( ) I can do most of the things I want to do, but I have some physical limitations.

( ) I can do some, but not all of the things I want to do, and I have many physical limitations.

( ) I can hardly do any of the things I want to do. <<Terminate

( ) [Do not read; record only] Don’t’ Know <<Terminate

13. On a scale from 1 to 5, where 1 indicates that you strongly disagree, and 5 indicates that you strongly agree, please tell me the number which indicates how much you agree or disagree with each statement.

9a.I have thought about taking action to [do something about my ongoing health problem].

( ) 1 Strongly Disagree <<Terminate

( ) 2

( ) 3

( ) 4

( ) 5 Strongly Agree

9b. I am taking action to [learn skills related to my health problem(s) by participating in a program] right now.

( ) 1 Strongly Disagree

( ) 2

( ) 3

( ) 4 <<Terminate

( ) 5 Strongly Agree <<Terminate

**TERMINATE LANGUAGE: Thank you very much for your time. We have recruited all of the persons like you that we need to talk to, so we won’t be able to include you in our study. Thank you for your time and interest. Have a good day/evening.

INVITE TO INTERVIEW

Thank you for answering my questions. As I mentioned this study is being conducted on behalf of the Centers for Disease Control and Prevention about materials about chronic disease management, and we would like to include your opinion.

In order for us to get your input, I would like to invite you to participate in focus group. The focus group will last about 90 minutes and will take place at ________________ on day/time _______________.

This is not a sales effort of any kind and no one will call on you as a result if your participation. To compensate you for your time and travel expenses, you will receive $50. Can we schedule your participation?

Check day and time; see details below.

NAME: _________________________________________________

ADDRESS: _________________________________________________

CITY: _________________________________________________

ZIP CODE: _________________________________________________

PHONE: (DAY) _____________________________________

(EVE) _____________________________________

(CELL) _____________________________________

(EMAIL) _____________________________________