Form Approved
OMB No. 0920-0572
Expiration Date 3/31/2018
Submission under
0920-0572 Health Message Testing System
Attachment 2: CONUS Consumer Message Testing for Zika Response Project
Community Leader Focus Group Screening Instrument
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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0572)
Community Leader Focus Group Screening Instrument
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 people 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 communication initiative. No preparation is needed for this focus group.
If you are eligible and choose to participate in the focus group, you will receive $50 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 being in this focus group and your participation is completely voluntary. These questions will take about 10 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 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. Results from this focus group may be used for purposes like presentations, publications, or for use with local health departments who are conducting similar health education initiatives. Your name or any other information identifying you would not be included or associated with the information you provide as part of the focus group.
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 Noting and Limiting Information
Instructions for screening staff: Only note information related to the questions in the screener. If an informant 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. . .”
I. BASIC DEMOGRAPHICS
What language are you most comfortable with for this interview?
1 English
2 Spanish
3 Equally comfortable in English and Spanish
4 Other [THANK AND END SCREENING]
[SCREENING OUT PROGRAMMING: UP TO 6 SPANISH-SPEAKING PARTICIPANTS TO BE INCLUDED IN MIAMI.]
In what ZIP Code do you currently live? (HMTS 8A)
_________
II. COMMUNITY LEADERSHIP ROLE
Now I want to ask about your current involvement in the community.
Are you currently involved with a group or organization where you are actively involved and seen as a person who has influence on others in the group or you are seen as a leader in the community? When I say influence or leadership, I’m referring to a role in which you have a recognized role and responsibility. This could be a volunteer role or an employment/professional role in a group or organization dedicated to the well-being and improvement of a community or group.
[READ LIST AND PROBE ON “YES” RESPONSES FOR THE PERSON’S ROLE/ACTIVITIES:]
1 Do you lead or give presentations to others during meetings, rallies, or events in the community?
2 Have you organized a meeting or gathering to talk about an issue or problem in your community in the last 6 months?
3 Have you organized or led a formal group, organization, or association that is currently active in the community?
4 Do you use your business or organization space to raise awareness for community issues?
5 Are you a leader of a religious organization or house of worship?
IF “YES” TO ANY OF THE ABOVE COMMUNITY ROLES/ACTIVITIES, GO TO 3 a.
1 3a. Please describe your role/s with the community group(s) you are involved with. ROLE. ______________________________________________________
0 IF THE PERSON DOES NOT HAVE ANY COMMUNITY LEADERSHIP ROLES/ACTIVITIES AS NOTED ABOVE GO TO 3b, THEN SCREEN OUT.
3b. Is there anyone else you can think of who fits this description? Would you be willing to share their name and contact information?
1Yes NAME AND CONTACT INFORMATION: __________________________
0 No
For what length of time have you been in your current community leadership position/s? If you currently have more than one community leadership position, please state the total number of years you’ve been in all of these current roles. For example: If you’ve been in a leadership position for the last 5 years, and another position for the last 3 years, we will count that as 5 years and thus will check the “5 – 10 years” option. [CHECK ONE.]
1 Less than 1 year
21-2 years
3 3-5 years
4 5-10 years
5 More than 10 years
99 Prefer not to answer
In what ZIP Code do you currently have a community leadership role?
_________ [SCREENING OUT PROGRAMMING: MIAMI-DADE COUNTY AND NEW ORLEANS, LA ARE THE ELIGIBLE ZIP CODES.]
For what type of group or organization are you a leader? [CHECK ALL THAT APPLY.]
1 Place of worship or other faith-based religious institution
2 Local government: (SPECIFY): ______________________________
3 Neighborhood organization or association
4 Cultural organization or association
5 Homeowner association
6 Small business association of a specific area like a geographic location, community or neighborhood (SPECIFY): ______________________________
7 Other association: (SPECIFY): ______________________________
9 Community-based non-profit organization (specify): ______________________________
10 Schools (grades K – 12)
11 Youth-serving organization [SCREEN OUT IF RESPONSE OPTIONS 7 – 11 ARE ALL CHILD OR YOUTH-FOCUSED ORGANIZATION AND THE ONLY RESPONSES. WE ARE TARGETING LEADERS WHO INFLUENCE OTHER ADULTS.]
12 Other organization (specify): ______________________________ [SCREEN OUT IF RESPONSE OPTIONS 7– 11 ARE ALL CHILD OR YOUTH-FOCUSED ORGANIZATION AND THE ONLY RESPONSES. WE ARE TARGETING LEADERS WHO INFLUENCE OTHER ADULTS.]
99 Prefer not to answer
Are you currently involved in any health-related work or community activities? Work includes paid employment and unpaid work.
1 Yes DESCRIBE: _______________________________
[SCREEN OUT PROGRAMMING: NO MORE THAN 50% OF EACH FG SHOULD HAVE PERSONS WITH HEALTH-RELATED EXPERIENCE
0 No
Are you currently involved in any work or community activities related to Zika? Work includes paid employment and unpaid work.
1 Yes DESCRIBE: ______________________________________________
[SCREEN OUT PROGRAMMING: NO MORE THAN 50% OF EACH FG SHOULD HAVE PERSONS WITH ZIKA-RELATED EXPERIENCE.]
0 No
III. ADDITIONAL DEMOGRAPOHICS
What is your age? (HMTS 25A)
__________ [RECORD AGE] [SCREENING OUT PROGRAMMING: COMMUNITY LEADERS MUST BE BETWEEN 18 YEARS OLD AND 69. FOR ALL OTHERS, THANK AND END SCREENING]
What is your gender? (HMTS 1A)
1 Male
2 Female
99 Prefer not to answer
[SCREENING OUT PROGRAMMING: FOCUS GROUPS OF 4-6 PERSONS TO SEEK DIVERSE GENDER MAKE-UP FOR EACH GROUP. OVERALL, SEEK AT LEAST 2 OF 6 PERSONS IN A FOCUS GROUP TO BE OF A DIFFERENT GENDER. ]
Please tell me your ethnic background. Do you consider yourself? (HMTS 5A)
1 Hispanic or Latino
0 Not Hispanic or Latino
88 Don’t Know/Not Sure (DO NOT READ)
99 Refused (DO NOT READ)
What is your race? [SELECT ONE OR MORE CATEGORIES] (HMTS 5A)
1 White
2 Black or African American
3 American Indian or Alaska Native
4 Native Hawaiian or Other Pacific Islander
5 Asian
88 Don’t Know/Not Sure (DO NOT READ)
99 Refused (DO NOT READ)
In what country were you born?
1 United States
2 United States territory
5 Other [SPECIFY:_______________]
9 Prefer not to answer
8a. [IF 8 = UNITED STATES TERRITORY] In what territory were you born?
1 American Samoa
2 Guam
3 Northern Mariana Islands
4 Puerto Rico
5 U.S. Virgin Islands
15. Do you work for any of the following types of employers? (HMTS 1B)
1 Government agency
2 Public health or health care agency [SCREEN OUT]
3 Marketing firm/agency [SCREEN OUT]
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.
[Do not provide reasons for ineligibility.]
Invitation:
[TEXT BELOW TO BE ADAPTED AS NEEDED FOR THE INFORMATION COLLECTION ACTIVITY.]
Based on your answers, you are eligible to participate in the focus group. As I mentioned earlier, we are talking to men and women about a health initiative 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 75 minutes. You will not be asked to buy anything. The risks to you for participating in this initiative are minimal. You may experience some discomfort when answering some of the more personal questions. You will be contacted one day before your focus group 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.
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. 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 or any other information identifying you with any comment you make in the focus group in any report, presentation or publication that we write. Results from this focus group may be used for purposes like presentations, publications or for use with local health departments who are conducting similar health education initiatives.
16. For participating in the focus group, you will receive $50 as a token of our appreciation. Will you be able to join us for a focus group?
1 Yes [SKIP TO TEXT BELOW]
0 No (Refuse to participate) [THANK AND END]
[IF “YES” TO INVITATION, READ THE FOLLOWING STATEMENTS…]
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 focus group is over.
Participant Information
Interviewer: _____________________
Date: _____________________
Call/Email/Text Reminder Date Sent: ____________________
Call/Email/Text Reconfirmation Date: ____________________ |
Name: ______________________________________________________________________
Zip code: ______________________________________________________________________
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. Thank you.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Cristina Booker |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |