Form 1 Attachment C Screening Questionnaire

ATTACHMENT C: Screening questionnaire

OMB No. 0925-0589

Expiration Date: July 17, 2017

STATEMENT OF PRIVACY: Collection of this information is authorized by The Public Health Service Act, Sections 411 (42 USC 285 a) and 412 (42 USC 285a-1.a and 285a1.3). The purpose of this data collection is to evaluate whether the respondent is eligible for further testing. Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private under the Privacy Act and will only be seen by people authorized to work on this project. The report summarizing the findings will not contain any names or identifying information. Identifying information will be destroyed when the project ends.

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN: 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0589-09). Do not return the completed form to this address.

INTRO

Screener for the Health Information National Trends Survey

NAME____________________________ PHONE__________________________

RESPONDENT Number ____________________

Hello, my name is (NAME) and I’m calling from Westat, a research company in Rockville. May I speak with (NAME)?

(reintroduce yourself if needed)

Thank you for your interest in the Health Information National Trends Survey (HINTS). I would like to tell you a little bit about the study and then I’ll ask you a few questions to see if you are eligible to take part.

We’re looking for people to participate in a session that can last about an hour and a half. In that session you would meet with a Westat researcher who would ask you some questions from a survey that we’re developing about how people look for and use health-related information. We need men and women over the age of 18 to take part in the interviews. All the interviews are being conducted at Westat, in Rockville MD, and everyone who participates will receive a cash gift of $50 in appreciation for their time.

If you are open to it, I would like to ask you a few questions to see if you’re eligible to participate.

IF NEEDED: Westat, a research company in Rockville, Maryland is conducting survey research for the U.S. Department of Health and Human Services to test questions for an upcoming national survey – we’d like to get your opinion on whether the questions are easy to understand and answer.

Q1. As I said, these interviews will take place at Westat’s headquarters, located on Research Boulevard in Rockville, Maryland. Are you within driving or commuting distance of our location?

PROVIDE MORE INFO IF NEEDED: Rt 28 off of 270. 1600 RESEARCH; NEAR THE CORNER OF RESEARCH AND GUDE DRIVE; AT ROCKVILLE METRO STATION ON THE RED LINE - 63 OR 54 BUS STOPS IN FRONT OF 1600; ETC.

1. Yes

2. No – TERMINATE AND THANK (“Based on the study design, our interviews are going to be conducted at Westat, so it looks like we can’t include you at this time.”)

Q2. ASK ONLY IF NOT OBVIOUS: Are you male or female?

• Male

• Female

Q3. Which of the following age categories are you in?

1. Under 18 – TERMINATE AND THANK (“Based on the requirements of this study, it looks like we can’t include you at this time. It is possible we will be calling you in the future for other studies.”)

2. 18 – 29

3. 30 – 44

4. 45 – 54

5. 55 – 64

6. 65 and older

INTERVIEWER: RECRUIT A MIX OF AGES.

Q4. Which of the following best describes your ethnicity? (Choose one)

1. Hispanic or Latino

2. Not Hispanic or Non-Latino

INTERVIEWER: RECRUIT NO MORE THAN 5 HISPANIC RESPONDENTS

Q5. Which of the following best describes your race? MARK ALL THAT APPLY.

1. American Indian or Alaskan Native

2. Asian

3. Black or African American

4. Native Hawaiian or Pacific Islander

5. White

INTERVIEWER: RECRUIT SOME NON-WHITE RESPONDENTS.

Q6. What is the highest level of education you have completed?

1. 11^th grade or less

2. 12 years of school, no diploma

3. GED or high school graduate (diploma)

4. Some college or technical school

5. College or technical school graduate

6. Post-graduate

INTERVIEWER: RECRUIT A MIX OF RESPONDENTS FROM EACH EDUCATION GROUP.

Q7. Have you ever been told by a doctor that you have any type of cancer?

1. Yes

2. No

INTERVIEWER: RECRUIT 5 CANCER SURVIVORS

Q8 Have you ever accessed your medical information online?

a. Yes

b. No

INTERVIEWER: RECRUIT 5 RESPONDENTS WHO HAVE ACCESSED AND 5 WHO HAVE NOT ACCESSED THEIR MEDICAL INFORMATION ONLINE,

Q9. When was the last time you participated in this type of interview session?

a. 6 months ago or less –THANK AND TERMINATE (“Based on the requirements of this study, it looks like we can’t include you at this time. It is possible we will be calling you in the future for other studies.)

b. More than 6 months but less than a year

c. More than a year ago

Q10. Do you now or have you ever worked for Westat?

1. Yes – THANK AND TERMINATE

2. No

Q11. Have you ever worked for US Department of Health and Human Services or any of its agencies?

1. Yes – What agency is/was that? IF NCI, THANK AND TERMINATE

2. No

Q12. Have you ever heard of the Health Information National Trends Survey?

a. Yes – Ask where they have heard of it? [Find out if they are a researcher that uses/used

HINTS data. If they are, TERMINATE AND THANK (“Based on the

requirements of this study, it looks like we can’t include you at this time. It is possible we will be calling you in the future for other studies.”)]

b. No

Q13. What is your zip code? ______________________

INTERVIEWER – INSERT A TABLE WITH THE RECRUITING CATEGORIES SO YOU CAN FILL IT OUT AS YOU TALK TO PEOPLE.

Requirement	Status
Adult Requirements
3 or 4 of these adults should have only a HS degree or GED
3 or 4 should be African American or other minority
3 or 4 should be 44 or younger
3 or 4 should be over the age of 44
Half should NOT have accessed their medical information
Half should have accessed their medical information online

If response to Q8 = B (i.e., they have done a cognitive interview from 6 months to a year ago), then read Closing #2

Otherwise read Closing #1

Closing #1

You are eligible to help with this research project. Just to give you a little more information, we’ll be asking people about how they get information about health and their thoughts about health-related topics. Please note, we will not share your personal information with anyone not involved in this study. Are you interested in participating?

YES — Thank you so much for your willingness to help us. If you are selected as a participant you will receive $50 cash upon completion of the interview. If you are chosen as a participant, I will call you back within two business days to set up a time for you to meet with someone from the study team.

NO — Thank you for taking the time to talk with me today and have a great (day/evening).

Closing #2

Thank you for answering those questions. We will contact you within the next week to indicate if you are eligible to help with this research project.

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