Recruitment screener

Attachment A – Recruitment Screener

Form Approved

OMB No. 0920-0572
Exp. Date 3/31/2018

CDC Air Quality Information Project

Participant Screener

CDC estimates the average public reporting burden for this collection of information as 5 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, MS D-74; 1600 Clifton Road NE, Atlanta, Ga. 30333; OMB No. 0920-0572.

Introduction

Hello, my name is _______________ and I’m from [name of company]. I’m calling on behalf of RTI International, a non-profit research organization, about a communication study testing some possible health messages. I’m not selling or promoting any product.

The purpose of this study is to hear your thoughts on materials about air quality and health. We will be conducting several small-group discussions on this topic in [city]. To see if you are eligible, I’d like to ask you some questions. If you are eligible and choose to participate, your comments will be kept secure and we will provide you with a $40 token of appreciation at the end of the group. May I proceed?

Yes  CONTINUE

No  [Thank respondent and end call.]

Eligibility Questions

1. What year were you born?

_____

1999 or Earlier  CONTINUE 2000 or Later  TERMINATE

2. Is English the primary language spoken in your home?

_____

Yes  CONTINUE No  TERMINATE

3. Have you ever been diagnosed by a doctor with any of the following health conditions? [Read options below]

   Asthma		 CONTINUE (GROUP A)
   Rheumatoid Arthritis
   COPD (Chronic Obstructive Pulmonary Disease)		 CONTINUE (GROUP B)
   Irritable Bowel Syndrome
   Heart Failure		 CONTINUE (GROUP C)
   Diabetes

4. Do you still have this health condition?

_____

Yes  CONTINUE No  TERMINATE

5. What is your current occupation?

Healthcare Provider (e.g., Physician, Nurse, Counselor)  TERMINATE

Researcher / Scientist  TERMINATE

All Other Occupations  CONTINUE

6. Have you participated in a focus group or interview on any topic in the last 6 months?

_____

Yes  TERMINATE No  CONTINUE

7. What is your sex?

Male		 CONTINUE
Female		 CONTINUE
SCREEN FOR A MIX

8. What is your ethnicity? [Read options below]

Hispanic or Latino		 CONTINUE
Not Hispanic or Latino		 CONTINUE
SCREEN FOR A MIX

9. What is your race? Select one or more. [Read options below]

American Indian or Alaska Native		 CONTINUE
Asian		 CONTINUE
Black or African American		 CONTINUE
Native Hawaiian or Other Pacific Islander		 CONTINUE
White		 CONTINUE
SCREEN FOR A MIX

10. What is the highest level of education you have attained?

Less than high school		 CONTINUE
High school graduate (or GED)		 CONTINUE
Some college or technical school but no degree		 CONTINUE
College graduate (2- or 4-year degree)		 CONTINUE
Some graduate school (No degree)		 CONTINUE
Graduate school degree		 CONTINUE
SCREEN FOR A MIX

Group Invitation:

Thank you for answering all of my questions. Based on your responses, you appear eligible to participate in our study and join one of our group discussions.

Each group will last about one hour and should be very interesting. No one will try to sell you anything, and no one will call you later because you participated. We will provide you with $40 at the end of the discussion as a token of appreciation for your time and participation. We can invite only a few individuals to take part, and if it’s okay, we would like to audio record the discussion. Can I schedule your participation?

The groups will take place on the following dates and times:

• Group A (Asthma): [DATE AND TIME TBD]

• Group B (COPD): [DATE AND TIME TBD]

• Group C (Heart Failure): [DATE AND TIME TBD]

Your participation in this study is very important. If for some reason you will not be able to attend, please let us know right away. You can call us anytime at [insert phone number], and if we are not here, please leave a message.

Closing for Ineligible Participants:

I’m sorry, but you are not eligible for this study. There are many possible reasons why people are not eligible. These reasons were decided earlier by the researchers. However, thank you for your interest in this study and for taking the time to answer our questions today.