0920-0840 Eligibility Sreener - Pregnant Women

Form Approved

OMB No. 0920-0840

Expiration Date: 01/31/2019

Eligibility Screening for Pregnant Women

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 (0920-0840)

Screening Form: Pregnant Women

To be administered to each potential participant individually, in private.

Thank you for expressing interest in our study! We are conducting this study to learn more about what women do before pregnancy and during pregnancy to keep their babies healthy. The study will involve one group interview, and will last approximately 1.5 – 2 hours. A focus group is a small group of people who gather to talk together about a topic. You will be compensated with a $25 gift card as a token of appreciation for your participation . I just need to ask you a few quick questions to make sure you are eligible to participate. Please remember that all of your answers will be confidential and we will not share any of this information outside of the study.

Are you interested in continuing?

Yes  Continue

No  Exit script

1. Do you currently live in [Kern County/ East Baton Rouge Parish]?

   1. Yes  Continue

   2. No  Exit script

2. Have you lived in [Kern County/ East Baton Rouge Parish] for at least 6 months?

   1. Yes  Continue

   2. No  Exit script

3. What is your age?

   1. ______

If under 18  Exit script

If 18 or over  Continue

4. Are you currently pregnant?

   1. Yes  Continue

   2. No  Exit script

5. When you think about all the money you make, from all different sources including government assistance (like Supplemental Security Income (SSI), or disability benefits), what is your yearly household income, before taxes? When we say ‘household’ we mean anyone who lives in your house and contributes to expenses. [Prompted]

   1. Less than $15,000

   2. Less than $20,000

   3. Less than $25,000

   4. Less than $35,000

   5. Less than $50,000

   6. Less than $75,000

   7. $75,000 or more
      
      

6. Are you Hispanic, Latino/a, or of Spanish origin?

   1. Yes

   2. No

   3. I don’t know

7. How do you describe your race? You can select all that apply. (Read answer choices aloud)

   1. White

   2. Black/ African American

   3. Asian

   4. American Indian / Alaska Native

   5. Pacific Islander

   6. Other (Specify):__________________

If eligible:

Great, thanks for answering my questions! It looks like you are eligible to participate in our study! For next steps, we just need to schedule you to participate in a focus group discussion. The focus group will last about 1.5-2 hours, and you will be compensated with a $40 gift card for participating. The focus group will take place in a location convenient to you, like in library or meeting space. Would you like to participate?

Yes  Continue to schedule participant

No  Ok, thank you for your time.

If NOT eligible:

Thank you so much for your time. Based on your responses, it appears that you are not eligible for the study we are conducting. Thank you for your time.