OADC Material Feedback Survey - Screener (Text)

Attachment D: OADC Message and Material Feedback Surveys — Screener Questions (text)

OADC Message and Material Feedback Surveys — Screener Questions (text)

Form Approved

OMB No. 0920-1050

Exp. Date 03/31/2018

Welcome

Welcome to the CDC Health Material Project!

You’re being asked to participate in a survey about a health material. We are conducting this survey on behalf of the Centers for Disease Control and Prevention (CDC), Office of the Associate Director for Communication (OADC).

Screener Questions

First, we want to see if you qualify.

We have a few simple questions to ask. At some point, the questions may end if you don’t qualify. This has nothing to do with you. We simply are looking for people who meet certain criteria.
 
Please tell us a little bit about yourself.

1. What year were you born? [End survey if participant is was born after 1997]

• [textbox with validation for year between 1910 and 2015]

[new survey page]

2. What is your sex?

• Male

• Female

3. What is your ethnicity?

• Hispanic or Latino

• Not Hispanic or Latino
  
  

4. What is your race? (Please select all that apply.)

• White

• Black or African American

• Asian

• Native Hawaiian or Other Pacific Islander

• American Indian or Alaska Native

5. What is the highest level of education that you’ve completed?

• Grade school

• Some high school

• High school graduate or completed GED

• Some college or technical school

• Received 4-year college degree

• Some post-graduate studies

• Received advanced degree

• Other: ________________

6. Which of the following categories best describes your total, annual household income?

• Under $20,000/year

• $20,001 - $30,000/year

• $30,001 - $40,000/year

• $40,001 - $50,000/year

• $40,001 - $50,000/year

• $50,001 - $60,000/year

• $60,001 - $80,000/year

• $80,000 - $100,000/year

• Over $100,000/year

• Prefer not to answer

7. Are you comfortable looking at materials on a computer in English and giving your opinion on these materials in English?

• Yes

• No
  
  

8. Do you, or does any member of your household or immediate family, work for:

• A market research company

• An advertising or public relations firm

• The media (TV/radio/newspapers/magazines)
  
  

9. Have you participated in a feedback session (e.g., focus group or other research) within the past 6 months?

• Yes

• No

10. How confident are you filling out medical forms by yourself?

• None of the time

• A little of the time

• Some of the time

• Most of the time

• All of the time