Appendix 2 OMB Burden Statement Sample

OMB Control No.: 0584-0523

Expiration Date: xx/xx/xxxx

APPENDIX 3 Sample Participant Screener

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection unless it displays a valid OMB Control number. The valid OMB number for this collection is 0584-0523. The time required for this information collection is estimated to average 15 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.

CONSUMER MESSAGE TESTING for the DIETARY GUIDELINES for AMERICANS and MYPLATE

Participant Screening Questionnaire

[Recruit 12 respondents to obtain 10 participants for each group.]

Hello, my name is _____with______. We are conducting a market research survey and I would like to ask you a few questions about nutrition and diet. I’m not trying to sell you anything.

1. Do you, or does anyone in your household, work in any of the following types of industries? [Record each “YES” response.]

Advertising .( )

Market research/Marketing ( )

Healthcare ( ) Terminate if “YES” to any

Nutrition or Fitness ( )

Pharmaceuticals ( )

2. Have you participated in a market research focus group in the past six months?

No ( ) Continue

Yes ( ) Terminate

Don’t know/Refused ( ) Terminate

3. What is your current age? ____ [Specify]

Under 20 ( ) Terminate

20 to 49 ( ) Recruit for “Younger” Group

(unless otherwise disqualified)

50 to 79 ( ) Recruit for “Older” Group

(unless otherwise disqualified)

Older than 79 ( ) Terminate

4. Record Gender [Do not ask unless unable to tell.]

Female ( ) Continue

Male ( ) Continue

5. Does anyone in your household, including yourself, have any of the following conditions that might affect the type or amount of food served to members of the household?

On a medically prescribed diet ( )

Allergic to wheat products or milk ( ) Terminate if “YES” to any

On medication or undergoing treatment for
a health condition such as heart disease,
cancer, or diabetes ( )

6. Do you consider yourself an “expert” in nutrition?

No ( ) Continue

Yes ( ) Terminate

Don’t know/Refused ( ) Terminate

7. What is your race or ethnicity?

[Read list and record one or more answer.]

American Indian or Alaska Native ( )

Asian ( )

Black or African American ( ) [Obtain a mix that is

Hispanic or Latino ( ) roughly proportional to

Native Hawaiian or Other Pacific Islander ( ) the local population.]

White ( )

8. What is your marital status?

Married ( )

Single, never married ( ) Recruit a mix

Separated/divorced/widowed ( )

9. Would you say your total annual household income is:

Under $25,000 ( )

$25,000 to $50,000 ( ) Recruit a mix

$50,000 to $75,000 ( )

Over $75,000 ( )

10. What is the highest level of education you have completed? [Do not read list]

Some high school ( )

High school graduate, some college,
vocational or technical school ( ) Recruit a mix

College graduate ( )

Post college ( )

11. In your opinion, what is the biggest health problem in America today, and why?

[After recording respondent’s answer, determine whether or not you feel this respondent would be useful in the group. Did he or she:

Give a full and complete answer?

Speak clearly, and without long pauses?

Answer enthusiastically?

It is most important that the respondent be articulate! If not, terminate.]

12. I would like to invite you to participate in a focus group discussion that will be held at our facility. The session will last approximately two hours.

During the focus group, you will have an opportunity to share your thoughts and opinions with other adults from your area. You will not be asked to buy any products, nor will you be contacted at a later date.

As a token of appreciation, you will receive $___ in cash at the conclusion of the session. [SPECIFIC AMOUNT WILL DEPEND ON LOCATION AND FACILITY] Would you be willing to participate?

Yes ( ) SCHEDULE

No ( ) THANK & END

GROUP TYPE DAY TIME

_________________________ _______________ _______

I will call you to remind you of this appointment. However, if for some reason you are unable to attend, please call me at (TELEPHONE NUMBER) so that I can find a replacement for you.

Thank you.

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