App C1_Web Survey Screener (WORD)

Appendix C1

Form Approved

OMB No. 0920-0822

Exp. Date: 6/30/2016

Public Reporting burden of this collection of information is estimated at 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 Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-1009).

National Intimate Partner and Sexual Violence Survey (NISVS)

Cognitive Laboratory Studies - Recruitment Web Screener

Thank you for your interest in participating in our study. RTI International is working with the Centers for Disease Control and Prevention (CDC) on a national study about health and injuries. We want to conduct in-person, private interviews to test some new questions we have developed for this survey, and our goal is to learn whether the questions are understood and can be answered by most people. This information will be used to finalize survey questions for the study that will be conducted in 2016.

If you meet the selection criteria and are able to participate in the interview during the time period, you will be called by a researcher to see if you want to set up an appointment for a 1 to 2 hour in-person interview. You would be one of 30 participants who help test this survey. You must be able to attend an interview in-person within 120 miles of Raleigh/Durham/Chapel Hill, NC. If yo complete the in-person interview you will receive $40 in cash upon completion of the interview.

In order to determine your eligibility, we need to ask a few questions:

1. Do you or your any of your family members work for RTI International?

1. Yes  INELIGIBLE

2. No

2. What is your gender?

1 Male

2 Female

3. Which of the following age groups includes your age?

1 Under 18  INELIGIBLE

2 18-25

3 26-34

4 35-49

5 50 or Older

4. How did you hear about this study?

1 Flyer

Where was the first flyer posted?_________________________

2 Word-of Mouth

3 Craigslist Advertisement

4 Newspaper Advertisement

Which newspaper______________________________________

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

1. No schooling

2. 1^st-8^th grade

3. Some high school

4. High school graduate

5. Technical or vocational school (attended or graduated)

6. Some college

7. 4-year college degree

8. Postgraduate degree

6. What is your race? You may identify more than one category. Would you say you are...

[Multiple responses allowed]

1 White or Caucasian

2 Black or African American

3 Asian

4 Native Hawaiian or other Pacific Islander, or

5 American Indian or Alaskan Native

6 Other (specify ____________________ )

7. Are you of Hispanic, Latin, or Spanish origin or descent?

1 Yes

2 No

Next there are going to be several questions about things that you may have experienced.

There will be some questions about being physically hurt by someone, having unwanted sexual experiences, and harassing and unwanted behaviors.

8. Since your 18th birthday, has anyone harassed you in a way that made you feel anxious or scared, such as watching or following you or repeatedly contacting you when you didn’t want them to?

1. Yes

2. No

9. Since your 18^th birthday, have you ever been slapped, hit, shoved, or experienced any other physical violence by a romantic or sexual partner?

1 Yes

2 No

10. Since your 18^th birthday, has anyone ever had sex or sexual contact with you or attempted to have sex with you without your consent?

1. Yes

2. No

INELIGIBLE: You are not eligible to participate in this study. Thank you for your interest. END SURVEY.

ELIGIBLE: Thank you for your responses! If you are eligible, someone will call you to confirm your responses and set up an in-person interview in the next two weeks. Please provide your contact information below, including the best number to reach you.

First Name______________________

Phone Number _________________________

Alternative Phone ______________________

Thank you!