Form Approved
OMB No. 0920-0572
Expiration Date: 3/31/2018
Attachment A: Public Screening Instrument – Individual Interviews
Interview |
Day 1 |
Day 2 |
#1 |
Public |
Public |
#2 |
Public |
Public |
#3 |
Public |
Public |
#4 |
Public |
Public |
Recruitment: Recruit 8 participants for onsite interviews
Incentive: $40 for each participant
Duration: 60 minutes for each session
Hello, my name is ______________ and I am calling from _________, a professional market research firm. I am not selling anything. We are recruiting participants for the Centers for Disease Control and Prevention (CDC) to gather feedback on information CDC provides. May I ask you a few questions to see if you are eligible to participate - this will take about 10 minutes?
[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: _____________________
[Terminate screener as soon as recruiting staff realizes the person does not speak or understand English]
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
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).
Do you, or does any member of your household or immediate family work: [1b]
01 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.)
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
As a radiation safety officer, health physicist or other radiation-related occupation
[IF YES TO ANY, THANK AND TERMINATE]
In which of the following categories does your age fall? [2a]
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 SO THAT INTERVIEWS TOGETHER ARE REFLECTIVE OF THE COMMUNITY]
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 SO THAT INTERVIEWS TOGETHER ARE REFLECTIVE OF THE COMMUNITY]
When you are at home, do you ever speak a language other than English?
Yes [THANK AND TERMINATE]
No
In an average week, how much time do you spend reading books, magazines, newspapers or professional journals? Using a Kindle or other book reader counts.
If < 2 hours, [THANK AND TERMINATE]
> 2 hours
This study will involve 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?
Yes
No [THANK AND TERMINATE]
What sex were you assigned at birth, on your original birth certificate? [1a]
01 Male
02 Female
[DOCUMENT ON GRID]
[RECRUIT ABOUT A 50/50 MIX]
Please indicate your race or ethnic background. [5a]
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
____ Don’t Know/Not Sure (Do Not Read)
____ Refused (Do Not Read)
[RECRUIT A MIX]
[DOCUMENT ON GRID]
Those are all of my questions. You do qualify for our interview and we would like to invite you to join us on _______ at ______ AM/PM. The discussion will last about 1 hour; it will be recorded (audio only) to be sure we get all the information. In appreciation for your time, you will be given $40 gift card at the time of the interview.
Are you willing to participate?
01 yes
02 no
Prior to the start of the interview, 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 interview or decide you can’t participate, please contact me at ________________.
Name_________________________________________________________________
Address________________________________________________________________
City/State/Zip___________________________________________________________
Day Number_________________________Night Number_____________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Carera, Karen |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |