Re-entry Messaging Following a Radiation Emergency

Form Approved

OMB No. 0920-0572

Expiration Date: 3/31/2018

Attachment A: Public Screening Instrument

Public

• Recruitment: Recruit 4 participants for each focus group in Atlanta, Georgia.

• Incentive: $50 for each participant

• Duration: 90 minutes for each group

Summary Table

Focus Groups	Location	Date/Time	Audience
#1	Atlanta, Georgia	TBD	Public
#2	Atlanta, Georgia	TBD	Public
#3	Atlanta, Georgia	TBD	Public
Day 2
#1	Atlanta, Georgia	TBD	Public
#2	Atlanta, Georgia	TBD	Public
#3	Atlanta, Georgia	TBD	Public

Good evening. My name is __________________ and I am calling from _______________, a market research firm. Today we are talking with people as part of a study for the Centers for Disease Control and Prevention. We are not selling anything. We have a few brief questions that will take no more than 10 minutes of your time, and if you qualify and are interested, we will invite you to take part in a discussion group with other people in your area that will take place at a later date.

[Terminate screener as soon as recruiting staff realizes the person does not speak or understand English]

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

[IF NO, THANK YOU and HANG UP]

Call back date/time: _____________________

Public reporting burden of this collection of information is estimated to average 10 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).

1. Have you participated in a focus group, in-depth interview, telephone survey, and/or online survey in which you were asked your opinions regarding a product, a service, or advertising within the past six months? [2b]

01 Yes [THANK AND TERMINATE]

02 No

2. Do you, or does any member of your household or immediate family work: [1b]

1. For a market research company

02 For an advertising agency or public relations firm

03 In the media (TV/radio/newspapers/magazines)

04 As a healthcare professional (doctor, nurse, pharmacist, dietician, etc.)

5. As an employee of:

• U.S. Department of Health and Human Services

• State or local health department

• Department of Homeland Security

• State or local emergency management agency

• Nuclear power plant

5. As a radiation safety officer, health physicist or other radiation-related occupation

[IF YES TO ANY, THANK AND TERMINATE]

3. In which of the following categories does your age fall? [2.a]

01 under 18 years of age [THANK AND TERMINATE]

02 18-24 years of age

03 25-34 years of age

04 35-44 years of age

05 45-54 years of age

06 55-64 years of age

07 65-74 years of age

08 75 years of age or older

[DOCUMENT ON GRID]

[RECRUIT A MIX WITHIN EACH GROUP]

[RECRUIT SO THAT GROUPS TOGETHER ARE REFLECTIVE OF THE COMMUNITY]

3. What is the highest level of education you have completed? [4a]

01 Grade school [THANK AND TERMINATE]

02 Less than high school graduate/some high school [THANK AND TERMINATE]

03 High school graduate or completed GED

04 Some college or technical school

05 Received four-year college degree

06 Some post graduate studies

07 Received advanced degree

08 Other: _____________________

[DOCUMENT ON GRID]

[RECRUIT A MIX WITHIN EACH GROUP]

[RECRUIT SO THAT GROUPS TOGETHER ARE REFLECTIVE OF THE COMMUNITY]

3. This study will involve respondents working with a moderator to review a series of healthcare messages. In these discussions, the moderator would be calling on you to explain what key words or phrases mean to you and to offer better words to describe key ideas. Each respondent will be called on repeatedly. Would you be comfortable doing this?

   1. Yes

   2. No [THANK AND TERMINATE]

3. What sex were you assigned at birth, on your original birth certificate?

01      Male

02     Female

[DOCUMENT ON GRID]

[RECRUIT ABOUT A 50/50 MIX]

3. Race:

01_ American Indian or Alaska Native

02_ Asian

03_ Black or African American

04_ Native Hawaiian or Other Pacific Islander

05_ White

Ethnicity:

01_ Hispanic or Latino

02_ Not Hispanic or Latino

[RECRUIT A MIX]

[DOCUMENT ON GRID]

3. Number of children (under the age of 18) living in your household? [14a]

01 None

02 1-2 children

03 3-4 children

04 5 or more children

[DOCUMENT ON GRID]

[NOT A SCREENING CRITERION]

Those are all of my questions. You do qualify for our discussion group and we would like to invite you to join us on _______ at ______ PM. The discussion will last about 90 minutes; it will be recorded (audio only) to be sure we get all the information. In appreciation for your time, you will be given $50 gift card/check at the time of the discussion.

Are you willing to participate?

01 yes

02 no

Prior to the start of the group discussion, you will receive an information sheet with such information as sponsorship of the study and contacts for more information. If after we hang up, you have a question about this group discussion or decide you can’t participate, please contact me at ________________.

Name_________________________________________________________________

Address________________________________________________________________

City/State/Zip___________________________________________________________

Day Number_________________________Night Number_____________________

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