Focus Group Screener And Follow Up Focus Group Screener

ATTACHMENT B: FOCUS GROUP SCREENER AND FOLLOW UP FOCUS GROUP SCREENER

OMB No. 0920-0572

Expiration Date: 3/31/2018

Public reporting burden of this collection of information is estimated to average 5 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia, 30333; ATTN: PRA (0920—0572).

Hello, my name is ________ . I work for a research company called ICF International, which is located near Washington, DC. I am calling because _______________ (Name of contact from HEADS UP partner organization) suggested that you (or your child) may be interested in participating in a 90-minute discussion group about concussion and the Centers for Disease Control and Prevention (CDC’s) HEADS UP materials. The purpose of the discussion group is to hear from other _____________ (audience) to understand ways that CDC can develop better materials for a range of audiences about concussion. Can I ask you a few questions to see if you (or your child) are able to participate in this discussion?

1. In the past three years, have you seen or read any of the Centers for Disease Control and Prevention’s (CDC) HEADS UP materials?

• Yes

• No

• Not sure

2. Would you describe yourself as: (select one)

• Youth athlete

• High school athlete

• Middle school athlete

• Parents of a youth athlete(s)

• Coach of youth athletes

• Health Care Provider

• School Professional

• None (END Survey)

3. What state do you live in? (Record state)

   • Northeast: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont, New Jersey, New York, Pennsylvania, Delaware

• Midwest: Illinois, Indiana, Michigan, Ohio, Wisconsin, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota

• South:, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia, Alabama, Kentucky, Mississippi, Tennessee, Arkansas, Louisiana, Oklahoma, Texas

• West: Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming, Alaska, California, Hawaii, Oregon, Washington

4. How did you learn about CDC HEADS UP materials? (Allow participant to provide answer, only give options if they cannot recall)

   • CDC HEADS UP Website

   • Emails from CDC

   • CDC HEADS UP Facebook page

   • National sports organization (list specific name of org)

   • Local sports organization (list name of org)

   • National education organization (list name of org)

   • School or local education association (list name of org)

   • Professional medical association (list name of org)

   • Health care system/ health care professional (list name of health care system)

   • A coach

   • A colleague or friend

   • A teammate

   • A parent

   • Other (record)

5. How often do you use or read CDC HEADS UP materials? (Ask if Q1=Yes)

• 3 or more times a year

• 1-2 times a year

• Less than once a year

6. If yes, who do you share them with? (Allow participant to provide answer, only give options if they cannot recall)

   • Youth athletes

   • Coaches

   • Health professionals

   • School professionals

   • Parents

   • Other: Please specify

7. RECRUITING Young Athletes: Parents of Athletes

1. How old are your children who play sports? (Start by discussing parent’s youngest child and recruit only one child per family)

• <12 (END Survey)

• 12-14(Recruit for younger triads)

• 15-18 (Recruit for older triads)

• >18 (END Survey)

2. What sport(s) does this child play? (END if participant names any sport aside from football, hockey, lacrosse, soccer, baseball, basketball, softball, cheerleading)

3. What is the gender of your youth athlete(s)?

• Male (SKIP to Question D; Recruit for male triads)

• Female (SKIP to Question D; Recruit for female triads)

• Other

• Prefer not to say

4. Would your child be more comfortable participating in a group discussion with girls or boys?

• Girls (Recruit for female triads)

• Boys (Recruit for male triads)

• Neither (END Survey)

8. Parents of Athletes Only

1. How old are your children who play sports? (Select all that apply, but segment based on youngest applicable age group)

• <12 (END Survey)

• 12-14(Recruit for younger triads)

• 15-18 (Recruit for older triads)

• >18 (END Survey)

2. What sport(s) do your children 18 and under play? (END if participant names any sport aside from football, hockey, lacrosse, soccer, baseball, basketball, softball, cheerleading)

3. What is the gender of your youth athlete(s)?

• Male (SKIP to Question D; Recruit for male triads)

• Female (SKIP to Question D; Recruit for female triads)

• Other

• Prefer not to say

9. Coaches Only

1. What sport(s) do you currently coach?

2. Where do you coach? (Select all that apply)

• Private league

• Community league

• Middle school

• High school

3. What age athletes do you coach? (Select all that apply, Recruit based on age of youngest athlete coached)

• <12 (Recruit for youngest triads)

• 12-14 (Recruit for middle triads)

• 15-18 (Recruit for oldest triads)

• >18 only (END Survey)

4. What gender athletes do you coach?

• Male

• Female

• Both

10. Health Care Providers Only

1. What is your specialty?

• Pediatrician

• Family Physician

• Emergency Medicine Physician

• Nurse Practitioner

• Certified Athletic Trainer

• Nurse

• Neurologist

• Neuropsychologist

• Neurosurgeon

• Sports Medicine Specialist

• Other

2. How often do you see or provide care to patients with a concussion or possible concussion?

11. School Professionals Only

1. What type of school professional are you?

• Administrator

• Counselor

• Nurse

• School Psychologist

• Teacher

• Other

Thank you for your willingness to participate in a discussion regarding CDC’s HEADS UP materials. We would like to conduct the focus group between [insert] and [insert]. When would you be available to participate?