Form Approved
OMB No. 0920-0572
Expiration Date 3/31/2018
Submission under
0920-0572 Health Message Testing System
Attachment 3: CONUS Consumer Message Testing for Zika Response Project
Consumer Focus Group Screening Instrument
Men and Women of Reproductive Age (18 – 49 years old)
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)
Consumer Focus Group Screening Instrument
Men and Women of Reproductive Age (18 – 49 years old)
Hello, my name is _______________ and I’m contacting you 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 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. 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 to screening staff: Only note information for 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. 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 INDIVIDUALS TO BE INCLUDED IN MIAMI.]
In what ZIP Code do you currently live? (HMTS 8A)
_________ [SCREENING OUT PROGRAMMING: ELIGIBLE ZIP CODES ARE:
Miami-Dade County, FL or New Orleans, LA]
Have you participated in a focus group, interview, or survey in the past 6 months? (HMTS 2B)
1 Yes
0 No
[ASK IF 3 = YES] 3a. What was/were the topics discussed? (HMTS 4B)
______________________________________ [RECORD TOPICS]
[SCREENING OUT PROGRAMMING FOR MIAMI-DADE COUNTY ONLY: IF PARTICIPATED IN A FOCUS GROUP OR INTERVIEW ABOUT ZIKA IN THE PAST 6 MONTHS, SCREEN OUT.]
What is your age? (HMTS 25A)
__________ [RECORD AGE] [SCREENING OUT PROGRAMMING: ELIGIBILITY FOR MEN AND WOMEN OF REPRODUCTIVE AGE: MUST BE BETWEEN 18 YEARS OLD AND 49 YEARS. FOR ALL OTHERS, THANK AND END SCREENING]
What is your gender? (HMTS 1A)
1 Male
2 Female
99 Prefer not to answer SCREEN OUT
[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.]
5a. [ASK IF 5 = FEMALE] Are you currently pregnant?
1 Yes
0 No SKIP TO 6
88 Not sure
99 Rather not say
5b. [ASK IF 5a = YES] In what pregnancy trimester are you 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)
88 Not sure
99 Rather not say
What is your current relationship status? Are you…? [READ RESPONSE OPTIONS ALOUD; CHECK ALL THAT APPLY] (HMTS 16A)
1 Single
2 Married to a man
3 Married to a woman
4 In a relationship with a man
5 In a relationship with a woman
6 Other relationship with a man
7 Other relationship with a woman
8 Divorced or widowed
99 Refused
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
6 Other country [SPECIFY:_______________]
99 Prefer not to answer
9a. [IF 10 = UNITED STATES TERRITORY] In what territory were you born?
1 American Samoa
2 Guam
3 Northern Mariana Islands
4 Puerto Rico
5 US Virgin Islands
Do you work for any of the following types of employers? (HMTS 1B)
1 Government agency SCREEN OUT
2 Public health or health care agency SCREEN OUT
3 Marketing firm/agency SCREEN OUT
4 None of the above
What is the highest grade or year of school you finished?
1 Never attended school or only attended kindergarten
2 Grades 1 through 8 (elementary)
3 Grades 9 through 11 (some high school)
4 Grade 12 or GED (high school graduate)
5 College 1 year to 3 years (some college or technical school)
6 College 4 years or more (college graduate)
9 Refuse to answer
Which best describes your total (personal or household) income during the past year? (HMTS 13A)
1 Less than $20,000
2 $20,000 to $30,000
3 $30,001 to $40,000
4 $40,001 to $50,000
5 $50,001 or more
99 Prefer not to answer
II. Health Literacy Questions1
[THESE SCREENING QUESTIONS WILL BE USED TO ASSESS LOWER LITERACY AUDIENCE.]
How confident are you filling out medical forms by yourself? [PROGRAMMING NOTE: CONFIDENT WITH FORMS]
5 Extremely “ADEQUATE” HEALTH LITERACY
4 Quite a bit “ADEQUATE” HEALTH LITERACY
3 Somewhat “INADEQUATE” HEALTH LITERACY
2 A little bit “INADEQUATE” HEALTH LITERACY
1 Not at all “INADEQUATE” HEALTH LITERACY
[SCREENING OUT PROGRAMMING: USE THESE HEALTH LITERACY LEVELS TO DETERMINE FOCUS GROUP COMPOSITION. FOR FOCUS GROUPS OF 4-6 PERSONS, AT LEAST 2 OF 6 PERSONS IN A FOCUS GROUP SHOULD BE OF A DIFFERENT LITERACY LEVEL]]
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 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.
18. 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.
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.
1 Question based on the following: Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Family Medicine. 2004;36(8)588–94. [PubMed] Retrieved October 27, 2016.
Men and Women of Reproductive Age (18 – 49 years old)
Screening Instrument– p.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Cristina Booker |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |