Focus Group Screener

[Form Not Approved]

OMB No. 0920-0572

Expiration Date 3/31/2018

Submission under

0920-0572 Health Message Testing System

Attachment 1:

Screening Instrument for Focus Groups

for Materials Testing for the

Domestic Readiness Initiative for Zika Virus

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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0572)

Screening Instrument for Focus Groups with Pregnant Women, Women who may Become Pregnant and Men with Female Partners

Introduction

Hello, my name is _______________ and I’m contacting you/calling on behalf of Abt Associates, a private research organization, and the Centers for Disease Control and Prevention.

We are not selling any product. We are contacting individuals in your area to join in a focus group. The purpose of the focus group is to get your honest opinions and feedback on a health education initiative. No preparation is needed for this focus group.

If you are eligible and choose to participate in the focus group you will receive $75 as a token of our appreciation for participating.

To see if you are eligible to participate in the focus group we need to ask you some personal questions. It is your choice to answer these questions.

I am required to share the following information with you: There are no costs to you for taking part in this project and your participation is completely voluntary. These questions will take about 5 minutes to complete. The initiative is funded by the Centers for Disease Control and Prevention. You may refuse to answer any questions and may choose to quit at any time. The risks to you for participating in this initiative are minimal. You may experience some discomfort when answering some of the more personal questions.

We can assure you that procedures to protect the privacy of your data will be strictly followed, with your answers kept in a secure database only accessible to the researchers working on this study. If you are not eligible and/or choose not to be part of the focus group all responses you give me today will be destroyed and you will not be contacted again.

These screening questions will only take a few minutes. May I ask you the questions now?

₁ Yes

₀ No [END SCREENING QUESTIONS]

Procedures for Recording and Limiting Information

Note to screening staff: Only record information for the questions in the screener. If an individual reveals additional personal information, thank them for being helpful, but guide them back to the screener questions—“That is interesting to learn, but can I now ask you about. . .”

1. What is your age?

_________ [RECORD AGE] [If under 18 years or over 44 years, screen out]

2. In what city and state/territory do you currently live in? _________________[RECORD CITY AND STATE]

[Screen out if not living in: Miami, FL, New Orleans, LA, or San Juan, PR]

3. What is your gender?

1. Male [skip to Q11]

2. Female

(99) Rather not say [screen out]

***SCREENER BEGINS FOR WOMEN***

3a. [ASK IF 3 = 2] Are you currently pregnant?

1. Yes [SKIP TO Q3b]

2. No [SKIP TO Q4]

(88) Not sure [screen out]

(99) Rather not say [screen out]

3b. [ASK IF 3a = 1] In what pregnancy trimester are you currently in?

1. First trimester of pregnancy (1-3 months)

2. Second trimester of pregnancy (4-6 months)

3. Third trimester of pregnancy (7-9 months)

4. Rather no say/Not sure

4. Were you pregnant at any time since May, 2015?

1. Yes

2. No

3. (88) Not sure [screen out]

(99) Rather not say [screen out]

5. Do you plan to become pregnant within the next two years?

1. Yes

2. No [screen out]

(88) Not sure [screen out]

(99) Rather not say [screen out]

6. What is your current relationship status? Are you…? [READ RESPONSE OPTIONS ALOUD; CHOOSE THE BEST OPTION]

(1) Single [SKIP TO Q7]

(2) Married to a man [SKIP TO Q7]

(3) Married to a woman [screen out]

(4) In a relationship with a man [SKIP TO Q7]

(5) In a relationship with a woman [screen out]

(6) Refused to answer [screen out]

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

1. Grade school

2. Less than high school graduate/some high school

3. High school graduate or completed GED

4. Some college or technical school

5. Received four-year college degree

6. Some post graduate studies

7. Received advanced degree

8. Other [SPECIFY] ______________________

8. Please indicate your ethnic background:

1. Hispanic or Latino

2. Not Hispanic or Latino

9. Please indicate your race (You may select one or more).

1. White/Caucasian

2. Black or African-American

3. American Indian or Alaska Native

4. Native Hawaiian or Other Pacific Islander

5. Asian

10. In what country were you born?

1. United States [SKIP TO 10a]

2. United States Territory [SKIP TO 10b]

3. Mexico

4. Cuba

5. Colombia

6. Other [SPECIFY:________]

7. Prefer not to answer

***SCREENER BEGINS FOR MEN***

11. [ASK IF 3=1] What is your current relationship status? Are you…? [READ RESPONSE OPTIONS ALOUD; CHOOSE BEST OPTION]

(1) Single [screen out]

(2) Married to a man [screen out]

(3) Married to a woman [SKIP TO Q11a]

(4) In a relationship with a man [screen out]

(5) In a relationship with a woman [SKIP TO Q11a]

(6) Refused to answer [screen out]

11a. How old is your partner? _________ [screen out if less than 18,

and above 44 years of age]

11b. Is your partner pregnant?

(1) Yes [SKIP TO 11c]

(2) No [SKIP TO 12]

11c. What pregnancy trimester is she currently in?

1. First trimester of pregnancy (first 3 months)

2. Second trimester of pregnancy (4-6 months)

3. Third trimester of pregnancy (7-9 months)

1. Not sure

(99) Rather not say

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

1. Grade school

2. Less than high school graduate/some high school

3. High school graduate or completed GED

4. Some college or technical school

5. Received four-year college degree

6. Some post graduate studies

7. Received advanced degree

8. Other [SPECIFY] ______________________

13. Please indicate your ethnic background:

1. Hispanic or Latino

2. Not Hispanic or Latino

14. Please indicate your race (You may select one or more).

1. White/Caucasian

2. Black or African-American

3. American Indian or Alaska Native

4. Native Hawaiian or Other Pacific Islander

5. Asian

15. In what country were you born?

1. United States

2. United States Territory

3. Mexico

4. Cuba

5. Colombia

6. Other [SPECIFY:________]

7. Prefer not to answer

[IF Q3A=1, THEN GROUP=PREGNANT WOMEN]

[IF Q3=2 AND (Q4=1 OR Q5=1) THEN GROUP= NON-PREGNANT WOMEN]

[IF Q3=1 AND Q11= 3 or 5 AND Q11a=18-44 THEN GROUP = MALE WITH FEMALE PARTNER]

ALL OTHERS ARE NOT ELIGIBLE

Closing for Ineligible Participants:

Thank you for answering all of my questions. You are not eligible to take part in this focus group. There are many possible reasons why people are not eligible. We value your interest. Thank you for being willing to help us. If you would like more information about Zika virus infection and the current outbreak, please visit www.cdc.gov/zika.

[Do not provide reasons for ineligibility.]

Invitation:

Based on your answers, you are eligible to participate in the focus group. As I mentioned earlier, we are talking to individuals about public health issues and we would like to include your opinions. We would like to invite you to take part in a focus group that will last about 60 minutes. For participating in the focus group you will receive $75.00.

We will be recording the focus group and some project staff from Abt and CDC may be observing the focus group. We may also use a live video or audio stream so project staff from Abt and CDC can observe from a computer or telephone in another location. In order to participate in the focus group, you must agree to being recorded and allowing staff from the Abt and CDC to observe. As I said, if you choose to attend, whatever you say will be kept private. We will never link your name with any comment you make in the focus group in any report that we write.

Will you be able to join us for a focus group on __________ at __________?

₁ Yes [SKIP TO TEXT BELOW]

₀ No (Refuse to participate) [THANK AND END]

You will be contacted one day before your interview to remind you of your appointment. We can assure you that procedures to protect the privacy of your data will be strictly followed, with your answers kept in a secure database only accessible to the researchers working on this study. Any information that you provide to us will be kept private. We're simply interested in your opinions. There is no preparation needed for this focus group

If you need to wear glasses either for reading or watching TV, please bring them with you to the focus group

Also, we need to let you know that there will not be any childcare provided at the facility, so please make the appropriate childcare arrangements if you have children.

In order for us to send you a reminder email with directions to the focus group and to call to remind you of your appointment time, I need to ask for your contact information. We will destroy this information after the interview is over.

Participant Information

Interviewer: _____________________

Date: _____________________

Date and Time of Focus Group ____________________________________

Call/Email/Text Reminder Date Sent: ____________________

Call/Email/Text Reconfirmation Date: ____________________

Name: ______________________________________________________________________

City and State: ______________________________________________________________________

Phone 1: ____________________________ Phone 2: _____________________________

Email: ______________________________________________________________________

What is the best time to reach you? What is the best telephone number to reach you at that time? If you do not answer, may we leave a private message at that number?

Best Time to Be Reached: ________________________________________

Best Phone Number: _______________________________________

Is there another time and number we can try if we miss you?

Alternate Phone Number: ________________________________________

Your participation in this health education initiative is very important. If for some reason you will not be able to attend, please let us know right away. You can contact us anytime at [insert phone number and email address]. If no one answers the phone, please leave a message. You can also contact us if you have any questions. Thank you.