Telephone Screening Script for Adult/Self-Responder or A

Attachment 3a – Telephone Screening Script for Adult/Self-Responder or Adult Proxy for Child 5-17

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 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; 1600 Clifton Road NE, 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 Center for Questionnaire Design and Evaluation Research

(CQDER) Recruiter/CQDER Staff for

Cognitive testing of Traumatic Brain Injury Questions recruited through newspaper advertisement/flyer

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

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

CQDER Recruiter/CQDER 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 [CQDER Recruiter/CQDER Staff‘s name. I am calling from the Centers for Disease Control and Prevention’s National Center for Health Statistics. You may remember that you responded to the advertisement we placed in the [name of newspaper] on [date] or flyer [looking for adults who may or may not have experienced a head or neck injury [within the past 12 months]/parents or guardians of children 5 to 17 who may or may not have experienced a head or neck injury [within the past 12 months].

 Wait for acknowledgment, such as, “Oh, yes, I remember.”

...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. Answering these questions is completely voluntary. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent. Is this a good time to ask the questions or should I call back later?

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

 If good time to talk, continue...

1. Where did you see our advertisement/flyer?

___________________________________________________

2. How old are you? [If under age 18, go to exit script 1]

________________

3. Do you have a child between the ages of 5 and 17?

   Yes

   No

4.   Have you/Has your child experienced a head or neck injury in the past 12 months?

   Yes

      If yes, please explain ____________________________________________________

   No

5.   How old is your child?

______________

1.  Are you the parent or guardian who is most knowledgeable about the physical health, and well-being of your [fill] year old?

   Yes           

   No [go to exit script 2]

6. What is the highest level of school you have completed?

 Less than High School (No Diploma or GED)

 High School Diploma or GED

 Associate Degree

 Some College

 Bachelor’s Degree

 Graduate Degree

6. Are you Spanish, Hispanic or Latino?

 Yes

 No

6. What race or races do you consider yourself to be? You may indicate more than one race.

 White

 Black or African American

 Asian

 American Indian or Alaska Native

 Native Hawaiian or Other Pacific Islander

[If the recruitment needs for certain groups have been achieved, go to exit script 3].

Entry Script:

...Based on your answers to the questions so far, we would like you to take part in our study. For this study we’d like you to come here to the National Center for Health Statistics in Hyattsville, MD/agreed mutual location. An interviewer will ask you a health questions head or neck injuries you/your child may have had. Then the interviewer will ask you to explain what you were thinking as you answered the questions. The interviewer will also ask you about your opinions of 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. 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 video recorded? Yes/No. [If no, ask if for permission to audio record]. Do you give permission to have your interview audio recorded? Yes/No. [If no, go to exit script 4. At a minimum audio recording is essential for this project].

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 8 a.m. to 6 p.m. Looking at your schedule, when would you be available to participate? Schedule. [If date/times not available go to exit script 5.]

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.

---------------------------------------------------------

Exit script 1: I’m 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: I’m sorry, you have not met one of the eligibility requirements for this particular study. However, I would like to put your name and the information you gave me into our database so that I can contact you about other studies coming up in the future. Is that ok? If yes, record name & number. If no: OK, thank you for your time.

Exit script 3: 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, would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.

Exit script 4: I’m sorry, willingness to be audio recorded is required in order to take part in this study and therefore we won’t be able to use you at this time. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.

Exit script 5: 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. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.

Attachment 3b – Telephone Screening Script for Parent/Guardian and Teen (12-17) Dyads

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 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; 1600 Clifton Road NE, 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 Center for Questionnaire Design and Evaluation Research

(CQDER) Recruiter/CQDER Staff for

Cognitive testing of Traumatic Brain Injury Questions recruited through newspaper advertisement/flyer

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

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

CQDER Recruiter/CQDER 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.

Note: Respondents will be directed to indicate on the voice mail system if they are calling in for themselves and to leave their age, or if they are calling in for their child and to leave the age of their child.

If R is aged 12-17 and has called in for themself, but the parent asks why you are calling or what the call is about:

…Hello, my name is [CQDER Recruiter’s/CQDER Staff’s name]. I am calling from the Centers for Disease Control and Prevention’s National Center for Health Statistics. Your child responded to an advertisement/flyer we placed looking for teens aged 12-17 and their parents to participate in one-on-one interviews in order to help us test survey questions on head and neck injuries. In order to determine if you and your child are eligible for our study, I’ll need a few minutes of your child’s time to ask some background questions and then a few minutes of your time to ask some additional background questions. Is this a good time to speak to [name/minor child name) or May I speak to you at this time?

If R is 12-17 years of age, Go To Intro A; If R is a parent/guardian of a teen, Go to Intro B.

Intro A

• If R has been successfully contacted and R is aged 12-17, continue...

...Hello, my name is [CQDER Recruiter’s/CQDER Staff’s name]. I am calling from the Centers for Disease Control and Prevention’s National Center for Health Statistics. You may remember that you responded to the [advertisement/flyer] we placed looking for teens 12 to 17 to participate in one-on-one interviews in order to help us test some survey questions on head and neck injuries.

• Wait for acknowledgment, such as, “Oh, yes, I remember.”

...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 I’ll need a few minutes of your parent’s time to ask some background questions. Answering these questions is completely voluntary. You and your parent’s answers will be kept strictly confidential. Is this a good time to ask the questions or should I call back later?

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

• If good time to talk, continue to teen screener…..

Intro B

• If R has been successfully contacted and P is a parent of a teen 12-17, continue...

...Hello, my name is [CQDER Recruiter’s/CQDER Staff’s name]. I am calling from the Centers for Disease Control and Prevention’s National Center for Health Statistics. You may remember that you responded to the [advertisement/flyer] we placed looking for teens aged 12 to 17 and their parents to participate in one-on-one interviews in order to help us test survey questions on head and neck injuries.

• Wait for acknowledgment, such as, “Oh, yes, I remember.”

...In order to determine if your child is eligible for our study, I’ll need a few minutes of your child’s time to ask some background questions. Then I’ll need a few minutes of your time to ask some additional background questions. Answering these questions is completely voluntary. Your and your child’s answers will be kept strictly confidential. Is this a good time to ask the questions or should I call back later?

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

• If good time to talk, continue...

Teen screener:

1. Where did you see our advertisement?

_____________________________________

2. According to the message left on our answering machine. You are _______ years old.

Is that correct? [If under age 12 or over age 17, go to exit script 1].

________

2a. [Ask if age was not left on the voicemail] How old are you? [If under age 12 or over age 17, go to exit script 1].

________

[If person is 12-17 years of age continue].

3.   Have you experienced a head or neck injury [in the past 12 months]?

          Yes

                  If yes, please explain ______________________________________________________________________

           No go to exit script 2

[If the recruitment needs for certain groups have been achieved, go to exit script 3. Otherwise continue].

Entry Script:

...Based on your answers to the questions so far, we would like you to take part in our study. For this study we’d like you to come here to the National Center for Health Statistics in Hyattsville, MD/agreed mutual location. An interviewer will ask you questions about head or neck injuries you may have had. Then the interviewer will ask you to explain what you were thinking as you answered the questions. The interviewer will also ask you about your opinions of 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. Your parent will be interviewed separately. Your parent will also answer questions about head or neck injuries you may have had. Your parent’s interview will also be private. 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 video recorded? Yes/No. [If no, ask if for permission to audio record]. Do you give permission to have your interview audio recorded? Yes/No. [If no, go to exit script 5. At a minimum audio recording is essential for this project]. For child 12-17 years of age; Say “In order to determine if you are eligible for our study, I need to ask your parent a few background questions. Would you please put your parent on the phone at this time. [GO TO parental script for minors below].

---------------------------------------------------------

Parental screener

In order to determine if your child is eligible for our study, I need to ask a few additional background questions about you.

1. Has your child experienced a head or neck injury in the past 12 months?

 Yes

If yes, please explain ____________________________________________________

 No

2. How old is your child?

______________

3. As the parent or guardian are you knowledgeable about the physical health, and well-being of your [fill]

year old?

 Yes

 No [go to exit script 2]

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

 Less than High School (No Diploma or GED)

 High School Diploma or GED

 Associate Degree

 Some College

 Bachelor’s Degree

 Graduate Degree

4. Are you Spanish, Hispanic or Latino?

 Yes

 No

4. What race or races do you consider yourself to be? You may indicate more than one race.

 White

 Black or African American

 Asian

 American Indian or Alaska Native

 Native Hawaiian or Other Pacific Islander

[If the recruitment needs for certain groups have been achieved, go to exit script 3].

Based your child’s and your answers to the background questions, you and your child are eligible to participate in our study. For this study we’d like you and your child to come [here to the National Center for Health Statistics in Hyattsville, MD/agreed mutual location]. You and your child will be interviewed separately. The interview will last no more than 60 minutes and you and your child would each receive $40. During these interviews, an interviewer will ask you and your child questions about your child’s head or neck injury. Then the interviewer will ask you and your child to explain what you were thinking as you answered the questions. The interviewer will also ask you and your child about your opinions of the questions. Your answers will help us find out if the survey questions will be easy for other people to answer. Everything you and your child say will be kept private. With your permission, we would like to video record both interviews. The recording is a record of what we asked and was said about the questions. Do you give permission to have your interview recorded? Yes/No. [If no, ask if for permission to audio record]. Do you give permission to have your interview audio recorded? Yes/No. [If no, go to exit script 4. At a minimum audiotaping is essential for this project]. Do you give permission to have your child’s interview video recorded? Yes/No. [If no, ask if for permission to audio record]. Do you give permission to have your child’s interview audio recorded? Yes/No. [If no, go to exit script 4. At a minimum audio recording is essential for this project]. So that your child feels comfortable answering the questions, you will not be allowed to watch/listen to the interview while it is being recorded or watch/listen to the recording at a later time.

All

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 holding [the one-on-one interviews (Day, Month/Date) through (Day, Month/Date) from 8 a.m. to 6 p.m. Looking at your schedule, when would you be available to come in? Schedule. [If date/times not available go to exit script 5.]

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

Exit script 1: I’m sorry, you have to be between 12 and 17 years of age to take part in this study and therefore we won’t be able to use you at this time. If aged <17: Thank you for your time. Your name and telephone number will not be added to our database. If aged >18: I would like to put your name and telephone number you gave me into our database so that I can contact you about other studies coming up in the future. Is that OK? If yes, record name and telephone number. If no: OK, thank you for your time. Your name and telephone number will not be added to our database.

Exit script2: I’m sorry, you have not met one of the eligibility requirements for this particular study. However, I would like to put your name and the information you gave me into our database so that I can contact you about other studies coming up in the future. Is that ok? If yes and aged >18, record information. If yes and aged 12-17, ask parent/guardian for permission to add minors name and phone number to our database. If parent/guardian gives permission, check this box . If no: OK, thank you for your time.

Exit script 3: 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 and aged 12-17, ask parent/guardian for permission to add minors name, phone number, age, educational level, and race and eligibility answers to our database. If parent/guardian gives permission, check this box . If no, would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes and aged 12-17, ask parent/guardian for permission to add minors name, phone number, age, educational level, and race to our database. If parent/guardian gives permission, check this box . If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.

Exit script 4: I’m sorry, willingness to be audio recorded is required in order to take part in this study and therefore we won’t be able to use you at this time. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes and aged 12-17, ask parent/guardian for permission to add minors name, phone number, age, educational level, and race to our database. If parent/guardian gives permission, check this box . If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.

Exit script 5: 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. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes and aged 12-17, ask parent/guardian for permission to add minors name, phone number, age, educational level, and race to our database. If parent/guardian gives permission, check this box . If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.

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