Screener

ID: __________

Form Approved

OMB No. 0920-0572

Exp. Date 3/31/2018

Attachment A1: Screener for Skin Cancer Focus Groups

Public reporting burden of this collection of information is estimated to average 3 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 (0920-0572)

NEEDS ASSESSMENT FOR SKIN CANCER MESSAGING

PARTICIPANT SCREENER

NOTES TO FACILITY

• Please do not call people who have done a focus group in the last 6 months.

• Please do not call people who have ever done 5 or more focus groups.

RECRUITING NOTES

• 8-10 participants per focus group, recruit 11.

• Separate groups by gender, race/ethnicity, and risk profile.

• All participants must be able to read, understand, and speak English.

Hello, my name is ______________ and I am calling from _______________ a research organization. We are recruiting participants for a research study sponsored by the Centers for Disease Control and Prevention (CDC). Participants in this study will receive $75. I am not trying to sell anything.

1. May I ask you a few questions to see if you are eligible to participate in this focus group?

____ Yes (CONTINUE)

____ NO (THANK AND TERMINATE)

[IF RESPONDENT INDICATES THAT THIS IS NOT A GOOD TIME, SCHEDULE A CALL BACK TIME]

2. When was the last time you participated in a research focus group or interview?

___ Less than 6 months ago (THANK AND TERMINATE)

___ 6 months to 12 months ago (CONTINUE)

___ More than 12 months ago (CONTINUE)

3. DOCUMENT GENDER. [ASK IF UNSURE]

___ Female (CONTINUE – RECRUIT TO FEMALE GROUPS)

___ Male (CONTINUE - RECRUIT TO MALE GROUPS)

4. How old are you? [READ RANGES]

____ 17 years old or younger (THANK AND TERMINATE)

____ 18-29 years (CONTINUE)

____ 30-44 years (CONTINUE)

____ 45 years old or older (THANK AND TERMINATE)

5. Which of the following best describes your ethnicity?

___ Hispanic or Latino (CONTINUE – RECRUIT TO HISPANIC GROUPS)

___ Not Hispanic or Latino (GO TO QUESTION # 6)

5a. Which of the following best describes your Hispanic/Latino heritage?

[RECORD HERITAGE. RECRUIT A MIX REFLECTIVE OF THE AREA]

1. Dominican or Dominican descent

_____ YES

_____ NO

2. Central American or Central American descent

_____ YES

_____ NO

3. Cuban or Cuban descent

_____ YES

_____ NO

4. Mexican or Mexican descent

_____ YES

_____ NO

5. Puerto - Rican or Puerto Rican descent

_____ YES

_____ NO

6. South American or South American descent

_____ YES

_____ NO

7. More than one (mixed) heritage

_____ YES

_____ NO

8. Other ____________[SPECIFY]

[GO TO QUESTION # 7]

6. Which of the following best describes your race? Please select one or more as applicable.

____ American Indian or Alaska Native (THANK AND TERMINATE)

____ Asian (THANK AND TERMINATE)

____ Black or African American (CONTINUE – RECRUIT TO BLACK/AFRICAN AMERICAN GROUPS)

____ Native Hawaiian or Other Pacific Islander (THANK AND TERMINATE)

____ White (THANK AND TERMINATE)

7. What is the highest level of education you have completed? (RECRUIT A MIX)

____ High School Diploma or less (CONTINUE)

____ Some college or associates degree (CONTINUE)

____ College degree (CONTINUE)

____ Advanced or postgraduate degree (CONTINUE)

8. Where you born in the United States?

____ YES (CONTINUE; GO TO QUESTION # 10)

____ NO (RECORD LOCATION OF BIRTH; GO TO QUESTION # 9)

8a. RECORD LOCATION OF BIRTH: ______________________________ (CONTINUE)

9. Have you lived in the United States 10 years or more?

___ YES (CONTINUE)

___ NO (THANK AND TERMINATE)

10. Which of the following do you visit and USE multiple times per week?

(CHECK ALL THAT APPLY)

____ Google search

____ Facebook

____ Twitter

____ YouTube

____ Snapchat

____ Instagram

____ Personal or work email (TERMINATE IF EMAIL ONLY)

11. Do you or any member of your household work as an employee or contractor in any of the following areas?

_____  Public health, such as the Centers for Disease Control and Prevention (CDC), local or state health department, or other public health organization

_____ Medical professions, such as dermatologist and aesthetician, in a health clinic; doctor’s office; hospital; or research institution.

____ Advertising

____ Marketing or market research

(IF “YES” TO ANY OF THE ABOVE IN QUESTION 11, THANK AND TERMINATE)

In considering your occupation or the type of work that you perform, please describe the location where you spend the majority of your work day? ____ I spend the majority of my work day indoors ____ I spend the majority of my work day outdoors, in direct sunlight  CHECK BOX 1 ____ I spend the majority of my work day outdoors, in shaded areas	BOX 1
How would you describe your natural skin color on parts of your body not exposed to the sun? ___ Pale or milky white  CHECK BOX 2 ___ Very light brown  CHECK BOX 2 ___ Light tan, brown, or olive ___ Brown, dark brown, or black	BOX 2
If you went out in the sun for an hour without sunscreen, a hat, or protective clothing, which one of these best describes what would happen to your skin? (READ ALL OPTIONS) ___ Get severe sunburn with blisters  CHECK BOX 3 ___ Have moderate sunburn with peeling  CHECK BOX 3 ___ Burn mildly with some or no tanning  CHECK BOX 3 ___ Turn darker without sunburn ___ Nothing would happen to my skin	BOX 3

In the past 12 months, have you ever used an indoor tanning device? _____ YES  CHECK BOX 4 _____ NO	BOX 4
What color are your eyes? ___ Blue  CHECK BOX 5 ___ Blue-grey  CHECK BOX 5 ___ Hazel  CHECK BOX 5 ___ Green  CHECK BOX 5 ___ Light brown ___ Dark brown/black ___ Mixed/other	BOX 5
What is your natural adult hair color? (check only one) IF “Gray”, PROBE: What was your natural hair color before you turned gray? ___ Light blond  CHECK BOX 6 ___ Blond  CHECK BOX 6 ___ Light brown  CHECK BOX 6 ___ Medium brown ___ Red-brown ___ Strawberry (reddish) blond  CHECK BOX 6 ___ Red  CHECK BOX 6 ___ Dark brown/black ___ Jet black	BOX 6

STOP. REVIEW BOXES 1-6.

RECORD NUMBER OF BOXES CHECKED ________.

IF 0-1 BOXES CHECKED, RECRUIT TO LOW RISK GROUPS.

IF 2+ BOXES CHECKED, RECRUIT TO ELEVATED RISK GROUPS.

Those are all of my questions.

IF INELIGIBLE: Thank you for your interest, but unfortunately you are not eligible for this study.

IF ELIGIBLE, READ THE FOLLOWING:

I’d like to invite you to take part in a research study that takes the form of a group discussion. The discussion will be held on [DATE AND TIME] and will last about two hours. No one will try to sell you anything in this discussion and no one will contact you for any sales purpose as a result of your participation in this study. We are only interested in your opinions and, as I mentioned earlier, you will receive $75 for taking part in this study.

If you need them, please remember to bring your reading glasses.

GIVE RESPONDENT DIRECTIONS TO FACILITY. We will call you the day before to remind you about this discussion. We will be counting on your attendance since we will only be inviting about ten people. So that we can be sure to start and end on time, please plan to arrive at our office fifteen minutes before the beginning of the group. We are counting on your participation, so please be sure to contact us as soon as possible if something arises and you find you can’t attend.

May I please get your:

Name: _____________________________________________________________________

Address: ______________________________ City:_________________ Zip: _____________

Email Address__________________________________________________________________

Home Phone: ____________________ Work Phone: _________________________

Thank you!

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