Pre-testing of Evaluation Surveys: An Examination of the Intersection of Domestic Human Trafficking with Child Welfare and Runaway and Homeless Youth Programs

Appendix B. Cognitive Screener

COG1. I am going to name three objects. Please wait until I say all three words, and
then repeat them. Remember what they are because I am going to ask you to name
them again in a few minutes. Please repeat these words for me: APPLE—TABLE—
PENNY. (3 TIMES)

DID THE RESPONDENT CORRECTLY REPEAT ALL THREE WORDS? Y / N
CS1. What year is this? _______________ CORRECT….. 1
CS2. What month is this? _______________ CORRECT…. 1
CS3. What is the day of the week? _______________ CORRECT…. 1
CS4. What were the three objects I asked you to remember?
_______________ CORRECT…. 1
_______________ CORRECT…. 1
_______________ CORRECT…. 1

Scoring Total Correct: _____/ 6_ Total Incorrect: _____/ 6_
(0-3 correct) FAIL. STOP
(4-6 correct) PASS. CONTINUE TO ELIGIBILITY SCREENER ON PAGE 2

The Paperwork Reduction Act Statement: This collection of information is voluntary and will be used to examine the intersection
of domestic human trafficking with child welfare and runaway and homeless youth programs. Information will be kept private to
the extent permitted by law. Public reporting burden for this collection of information is estimated to average 17 minutes per
response, including the time for reviewing instructions, gathering and maintaining the data needed, 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. The OMB number for this information collection is [NUMBER] and the
expiration date is [DATE]. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to Meredith Dank; [email protected].

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