0920-16AEE CQDER CMS Att 3ab Telephone Screener

Attachment 3a: English language - Eligibility Screening Script

Note to reviewers: Cognitive interviews will be conducted in Spanish only. For ease of review, the eligibility screening script is included in both English and Spanish.

RESPONDENT NUMERIC IDENTIFIER: ___________________________

The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Public reporting burden for 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222).

Form Approved OMB #0920-0222; Expiration Date: 07/31/2018

Sample screening script for respondent contact by NORC for the NCHS & CMS Spanish Cognitive Interviewing Study

Dial respondent’s telephone number [hereafter referred to as R] as indicated on voice mail system/email system.

 Note: Speak only to R. If the number is answered by voice mail/answering machine, call back at another time.

NORC Recruiter/NORC Staff: Good morning/afternoon, may I speak to (name)?

 If R is not available or not at home, say, “Thank you” and try again at another time.

If the person who answered the phone (NOT R) asks, “Who is calling?” or “What’s this about?” say, “I am returning their call to me. I’ll try to reach them at another time.

 If R has been successfully contacted, continue...

...Hello. My name is [NAME] and I work for NORC at the University of Chicago and we are conducting a health study on behalf of the National Center for Health Statistics and the Centers for Medicare and Medicaid Services. I’m calling about your interest in participating in the health study. Is this a good time?

 If not a good time to talk, schedule a time to call back.

 If good time to talk, continue...

[IF YES] Let me tell you a little bit about what we are going to do and then you can let me know if you are still interested. First, are you 18 years or older? [IF NO, GO TO EXIT SCRIPT #1]

[IF YES] We are conducting a study to test questions that may be added to national surveys. If you agree to participate in this interview, an interviewer will ask you to fill out a questionnaire. Then the interviewer will ask you to explain what you were thinking as you answered the questions. Your answers will help us find out if the survey questions will be easy for other people to answer. Everything you say will be kept private. Some people may view some questions as sensitive – the questions you will be asked range from healthcare to basic demographic questions such as race, and education. The interview will take no more than 60 minutes. You will receive $40 as an incentive for participating in this survey.

• [IF YES] Great. In order to determine if you are eligible for our study, I’ll need a few minutes of your time to ask some background questions. Then we can schedule an appointment time for you. Answering these questions is completely voluntary. We are required by law to use your information for statistical purposes only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent.

• [IF NO] That's okay. We appreciate your interest. But for research purposes, we would like to know why you choose not to participate. NOTE TO RECRUITER: IF POTENTIAL RESPONDENT DECIDES AFTER HEARING ABOUT THE STUDY THAT HE/SHE DOES NOT WANT TO PARTICIPATE, ASK WHY NOT AND OFFER TO ANSWER QUESTIONS. RECORD THE RESPONDENT’S REASONS FOR NOT PARTICIPATING BELOW:

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1. Are you male or female?

   1. MALE

   2. FEMALE

2. Would you be able to come in person to one of our offices in [fill city] to complete an interview?

   1. YES

   2. NOFIND OUT WHERE RESPONDENT WOULD LIKE TO BE INTERVIEWED; WE WILL DETERMINE IF TRAVEL ARRANGEMENTS CAN BE MADE; CONTINUE SCREENING.

3. How old are you?

_______ years

4. What is the highest degree or level of school you have completed?

   1. NO SCHOOLING COMPLETED

   2. NURSERY SCHOOL TO 8TH GRADE

   3. 9TH-12TH GRADE, NO DIPLOMA

   4. HIGH SCHOOL GRADUATE (HIGH SCHOOL DIPLOMA OR THE EQUIVALENT)

   5. VOCATIONAL/TECHNICAL/BUSINESS/TRADE SCHOOL CERTIFICATE OR DIPLOMA (BEYOND THE HIGH SCHOOL LEVEL)

   6. SOME COLLEGE, BUT NO DEGREE

   7. ASSOCIATE DEGREE

   8. BACHELOR'S DEGREE

   9. MASTER'S, PROFESSIONAL OR DOCTORATE DEGREE

   10. DON’T KNOW

   11. REFUSED

5. Are you of Hispanic, Latino, or Spanish origin?

   1. YES

   2. NO

6. What is your race? Please choose one or more.

   1. American Indian or Alaska Native

   2. Asian

   3. Black or African American

   4. Native Hawaiian or other Pacific Islander

   5. White

   6. DON’T KNOW

   7. REFUSED

7. Do you, personally, identify as lesbian, gay, bisexual, or transgender?

   1. Yes

   2. No

[IF RESPONDENT ASKS WHAT TRANSGENDER MEANS:

SOME PEOPLE DESCRIBE THEMSELVES AS TRANSGENDER WHEN THEY EXPERIENCE A DIFFERENT GENDER IDENTITY FROM THEIR SEX AT BIRTH. FOR EXAMPLE, A PERSON BORN INTO A MALE BODY, BUT WHO FEELS FEMALE OR LIVES AS A WOMAN WOULD BE TRANSGENDER. SOME TRANSGENDER PEOPLE CHANGE THEIR PHYSICAL APPEARANCE SO THAT IT MATCHES THEIR INTERNAL GENDER IDENTITY. SOME TRANSGENDER PEOPLE TAKE HORMONES AND SOME HAVE SURGERY. ]

[If the recruitment needs for certain groups have been achieved, go to exit script 2].

With your permission, we would like to record your interview. The recording is a record of what we asked and what you said about the questions. Do you give permission to have your interview audio recorded? Yes/No. [NOTE TO RECRUITER: THIS QUESTION IS NOT MEANT TO ASK FOR CONSENT. RESPONDENTS WILL BE ASKED AGAIN ABOUT RECORDING DURING THE CONSENT PROCESS. THEY WILL HAVE THE OPPORTUNITY TO DECIDE NOT BE RECORDED AND STILL PARTICIPATE IN THE INTERVIEW. WE PREFER TO RECRUIT RESPONDENTS WHO ARE LIKELY TO CONSENT TO RECORDING.]

1. YES

2. NO

Do you have any questions at this point? Pause to answer questions. If (not/you have no other questions), then let’s get you on the schedule, ok? We will be interviewing (Day, Month/Date) through (Day, Month/Date) from [fill] a.m. to [fill] p.m. Looking at your schedule, when would you be available to participate? Schedule. [If date/times not available go to exit script 3.]

A reminder call will be made to you a few days in advance. Should you have any questions or need to change your appointment, please feel free to contact me [name] at [phone number]. Thank you for responding to our ad, and I look forward to seeing you here at (DATE/TIME) Get respondent to cite date & time if possible.

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Exit script 1: I am sorry, you have to be over the age of 18 to take part in this study and therefore we won’t be able to use you at this time. We appreciate your call and thank you for your interest in our study.

Exit script 2: Based upon your answers, it seems that we may already have a number of volunteers with very similar answers to yours. At this point we need to talk with people with some different characteristics. However, if we have cancellations or other slots open up, I may wish to call you back. Would it be okay if I kept your name, telephone number, and the information you provided in response to the eligibility questions until the end of this study? If yes, make notation. If no, OK, thank you for your time. We appreciate your call and thank you for your interest in our study.

Exit script 3: I see...ok, we were hoping to complete this particular study between (Month/Date) and (Month/Date), so it looks like we won’t be able to schedule you at this time. We appreciate your call and thank you for your interest in our study.

Attachment 3b: Spanish language - Eligibility Screening Script

Note to reviewers: Cognitive interviews will be conducted in Spanish only. For ease of review, the eligibility screening script is included in English. See Attachment 3a.

RESPONDENT NUMERIC IDENTIFIER: ___________________________

El Acta del Servicio de Salud Pública nos otorga la autoridad para hacer este estudio (42, Código de Leyes de los Estados Unidos 242K). Toda información que pueda permitir identificar a algún individuo, práctica o establecimiento se mantendrá confidencial, será usada solo para propósitos estadísticos por el personal de NCHS, sus contratistas y agentes solamente cuando sea requerido y con los controles necesarios, y no será divulgada ni entregada a otras personas sin el consentimiento del individuo o establecimiento como lo establece la sección 308(d) del Acta del Servicio de Salud Pública (42 Código de Leyes de los Estados Unidos 242m) y el Acta de Protección de la Información Confidencial y Eficiencia Estadística (PL-107-347).

Se calcula que el tiempo que le llevará al público cumplir con este pedido de información es de un promedio de 10 minutos por participante, incluyendo el tiempo que tomará revisar las instrucciones, buscar fuentes de datos preexistentes, juntar y mantener los datos necesarios y completar y revisar el pedido de información. Ninguna agencia puede llevar a cabo o patrocinar un pedido de información a menos que tenga a la vista un número vigente de control de OMB, y a ninguna persona se le puede exigir que responda en ese caso. Envíe sus comentarios con respecto al cálculo de tiempo o de cualquier otro aspecto de este pedido de información, incluyendo sugerencias para reducir el tiempo que toma, a CDC/ATSDR Information Collection Review Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222).

Form Approved OMB #0920-0222; Fecha de Vencimiento: 07/31/2018

Sample screening script for respondent contact by NORC for the NCHS & CMS Spanish Cognitive

Interviewing Study

Dial respondent’s telephone number [hereafter referred to as R] as indicated on voice mail system/email system.

 Note: Speak only to R. If the number is answered by voice mail/answering machine, call back at another time.

NORC Recruiter/NORC Staff: Buenos días/Buenas tardes, ¿puedo hablar con (name)?

 If R is not available or not at home, say, “Gracias” and try again at another time.

If the person who answered the phone (NOT R) asks, “¿Quién habla?” or “¿Por qué llama?” say, “Le estoy regresando una llamada. Voy a tratar de llamarle en otro momento.

 If R has been successfully contacted, continue...

...Hola. Mi nombre es (NAME) y trabajo para NORC en la Universidad de Chicago y nosotros estamos conducting a health study on behalf of the Centro Nacional de Estadísticas de Salud and the Centers for Medicare and Medicaid Services. Estoy llamando sobre su interés en participar en el estudio de salud. ¿Ahora es un buen momento para hablar

 If not a good time to talk, schedule a time to call back.

 If good time to talk, continue...

[IF YES] Permítame explicarle un poco más de qué se trata y después me dice si aún está interesado(a) en participar. Antes de empezar, ¿tiene usted 18 años o más? [IF NO, GO TO EXIT SCRIPT #1]

[IF YES] Estamos llevando a cabo un estudio para probar preguntas que se puedan añadir a encuestas nacionales.If you agree to participate in this interview, an interviewer will ask you to fill out a questionnaire. Then the interviewer will ask you to explain what you were thinking as you answered the questions. Your answers will help us find out if the survey questions will be easy for other people to answer. Everything you say will be kept private. A algunas personas puede parecerles que algunas de las preguntas son demasiado personales – las preguntas que se le harán van desde temas como su acceso a la atención médica y sus fuentes habituales de la misma, hasta preguntas personales tales como raza y educación. La entrevista le tomará aproximadamente 60 minutos. Usted recibirá $40 dólares por su participación en este estudio.

• [IF YES] Muy bien. In order to determine if you are eligible for our study, I’ll need a few minutes of your time to ask some background questions. Entonces podremos programar una cita para usted. Answering these questions is completely voluntary. We are required by law to use your information for statistical purposes only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent.

• [IF NO] Esta bien, no hay problema. Apreciamos su interés. Pero para los propósitos de este estudio, nos gustaría saber por que decidio no participar. NOTE TO RECRUITER: IF POTENTIAL RESPONDENT DECIDES AFTER HEARING ABOUT THE STUDY THAT HE/SHE DOES NOT WANT TO PARTICIPATE, ASK WHY NOT AND OFFER TO ANSWER QUESTIONS. RECORD THE RESPONDENT’S REASONS FOR NOT PARTICIPATING BELOW:

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1. ¿Es usted hombre o mujer?

   1. HOMBRE

   2. MUJER

2. ¿Podría venir a una de nuestras oficinas en [fill city] para completar una entrevista?

1. YES

3. NO -> FIND OUT WHERE RESPONDENT WOULD LIKE TO BE INTERVIEWED; WE WILL DETERMINE IF TRAVEL ARRANGEMENTS CAN BE MADE; CONTINUE SCREENING.

3. ¿Cuántos años tiene?

_______ years

4. Cuál es el grado o nivel de estudios más alto que usted ha completado?

1. NO TIENE ESTUDIOS

2. PREESCOLAR A 8º. GRADO

3. 9º -12º GRADO, SIN DIPLOMA

4. GRADUADO(A) DE HIGH SCHOOL (CON DIPLOMA DE HIGH SCHOOL O SU EQUIVALENTE)

5. VOCACIONAL/TÉCNICO/DE NEGOCIOS/CERTIFICADO O DIPLOMA DE ESCUELA DE

OFICIOS (MÁS ALLÁ DEL NIVEL DE HIGH SCHOOL)

6. ALGO DE COLLEGE O UNIVERSIDAD, PERO SIN DIPLOMA

7. GRADUADO DE UNIVERSIDAD DE 2 AÑOS CON GRADO DE ASOCIADO

8. GRADUADO DE UNIVERSIDAD DE 4 AÑOS CON GRADO DE BACHILLERATO

9. MAESTRÍA, TÍTULO PROFESIONAL O DOCTORAL

10. DON’T KNOW

11. REFUSED

5. Es usted de origen hispano, latino o español?

1. YES

2. NO

6. De qué raza es? Por favor elija una o más respuestas.

1. Indígena de las Américas o nativa de Alaska

2. Asiática

3. Negra o afroamericana

4. Nativa de Hawái u otras Islas del Pacífico

5. Blanca

6. DON’T KNOW

7. REFUSED

7. ¿Se identifica usted como lesbiana, gay, bisexual o transgénero?

1. Sí

2. No

[IF RESPONDENT ASKS WHAT TRANSGENDER MEANS:

ALGUNAS PERSONAS SE DESCRIBEN A SÍ MISMAS COMO TRANSGÉNERO CUANDO SIENTEN QUE SU IDENTIDAD DE GÉNERO ES DIFERENTE A LA DE SU SEXO AL NACER. POR EJEMPLO, UNA PERSONA QUE NACIÓ CON EL CUERPO DE UN HOMBRE, PERO QUE SE SIENTE MUJER O VIVE COMO MUJER, SERÍA TRANSGÉNERO. ALGUNAS PERSONAS TRANSGÉNERO CAMBIAN SU APARIENCIA FÍSICA PARA QUE CORRESPONDA CON SU IDENTIDAD DE GÉNERO INTERNA. ALGUNAS PERSONAS TRANSGÉNERO TOMAN HORMONAS Y ALGUNAS SE SOMETEN A CIRUGÍAS. ]

[NOTE TO RECRUITER: THIS QUESTION IS NOT MEANT TO ASK FOR CONSENT. RESPONDENTS WILL BE ASKED AGAIN ABOUT RECORDING DURING THE CONSENT PROCESS. THEY WILL HAVE THE OPPORTUNITY TO DECIDE NOT BE RECORDED AND STILL PARTICIPATE IN THE INTERVIEW. WE PREFER TO RECRUIT RESPONDENTS WHO ARE LIKELY TO CONSENT TO RECORDING.]

1. Sí

2. No

¿Tiene alguna pregunta por el momento? Pause to answer questions. Si (no/no tiene más preguntas), hagamos la cita para la entrevista, ¿Está bien? Estaremos haciendo entrevistas del (día, mes/fecha) al (día, mes/fecha) de [fill] a.m. a [fill] p.m. Por favor fíjese en su calendario y dígame cuándo estaría disponible para participar. Schedule. [If date/times not available go to exit script 3.]

Unos días antes, le llamaremos para recordarle de su cita. Si tiene alguna pregunta o necesita cambiar la cita, por favor no dude en llamarme; mi nombre es [name] y mi número de teléfono es [phone number]. Gracias por contestar a nuestro anuncio, y espero verle aquí el (DATE/TIME) Get respondent to cite date & time if possible.

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Exit script 1: Lo lamento, pero tienes que ser mayor de 18 para participar en este estudio, y por lo tanto, no podemos entrevistarte en este momento. Agradecemos tu llamada y te agradecemos por tu interés en nuestro estudio.

Exit script 2: De acuerdo a sus respuestas, parece que ya tenemos suficientes voluntarios con respuestas muy semejantes a las de usted. En este momento necesitamos hablar con gente con algunas características diferentes. Sin embargo, si tenemos alguna cancelación o algún horario disponible, me gustaría volver a llamarle. ¿Está bien si guardo hasta el final de este estudio su nombre, número de teléfono y la información que nos dio al responder a las preguntas para ver si era elegible? If yes, make notation. If no: Bueno, gracias por su tiempo. Agradecemos tu llamada y te agradecemos por tu interés en nuestro estudio.

Exit script 3: Ah, bueno. Teníamos pensado completar este estudio entre el (día) de (mes) y el (día) de (mes), así es que parece que no podremos hacer una cita con usted en este momento. Agradecemos tu llamada y te agradecemos por tu interés en nuestro estudio.

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