Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/xxxx
Recruit
20 males for telephone interviews
Numbers in parentheses in each question correspond to question numbers in “Health Message Testing System: Question Bank” –
Recruiters need not attend to these numbers.
Good evening. My name is __________________ and I am calling from _______________, a market research firm. We are following up with you regarding your interest in participating in a discussion about lupus sponsored by Centers for Disease Control and Prevention. We have a few brief questions that will take just 10 minutes of your time, and if you qualify and are interested, we will invite you to take part in a discussion group with other people in your area that will take place at a later date.
Have you been diagnosed with Systemic Lupus Erythematosus (SLE) by a rheumatologist? (A.43.a)
01 YES
02 NO [THANK AND TERMINATE]
[DOCUMENT ON GRID]
When were you diagnosed?
01 FEWER THAN 3 YEARS [RECRUIT 10 MEN]
02 3 OR MORE YEARS [RECRUIT 10 MEN]
[RECORD ABSOLUTE VALUE (YEAR or NUMBER OF YEARS AGO); DOCUMENT ON GRID]
In which of the following categories does your age fall?
01 under 18 years of age [THANK AND TERMINATE]
02 18-24 years of age
03 25-34 years of age
04 35-44 years of age
05 45-54 years of age
06 55-64 years of age
07 65-74 years of age
08 75 years of age or older [THANK AND TERMINATE]
[DOCUMENT ON GRID]
What is the highest level of education you have completed?
01 Grade school
02 Less than high school graduate/some high school
03 High school graduate or completed GED
04 Some college or technical school
05 Received four-year college degree
06 Some post graduate studies
07 Received advanced degree
08 Other: _____________________
[DOCUMENT ON GRID]
Gender
01 Male [RECRUIT 16 FOR INTERVIEWS]
02 Female [RECRUIT FOR FOCUS GROUPS; SEE FOCUS GROUP SCREENER]
[DOCUMENT ON GRID]
Please tell me about your race and ethnic background.
Are you:
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Don’t Know/Not Sure (DO NOT READ)
Refused (DO NOT READ)
Please select one or more of the following:
Race:
White
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Asian
[DOCUMENT ON GRID]
[RECRUIT 4 “WHITE” MEN WHO ANSWERED Q2. FEWER THAN 3 YEARS]
[RECRUIT 4 “ALL OTHER RACES” MEN WHO ANSWERED Q2. FEWER THAN 3 YEARS]
[RECRUIT 4 “WHITE” MEN WHO ANSWERED Q2. MORE THAN 3 YEARS SINCE DIAGNOSIS]
[RECRUIT 4 “ALL OTHER RACES” MEN WHO ANSWERED Q2. MORE THAN 3 YEARS SINCE DIAGNOSIS]
In what state, city, and zip code do you currently live? ENTER FIVE DIGIT ZIP CODE.
[DOCUMENT ON GRID]
Which of the following categories best describe your total, annual household income?
Under $20,000/year
$20,001 - $30,000/year
$30,001 - $40,000/year
$40,001 - $50,000/year
$50,001 - $60,000/year
$60,001 - $80,000/year
$80,001 - $100,000/year
Over $100,000/year
[DOCUMENT ON GRID]
ASSESS AND VERIFY ABILITY TO SPEAK AND UNDERSTAND ENGLISH
ASSESS AND VERIFY WILLINGNESS TO COMPLY WITH ADDITIONAL RECRUITING CRITERIA (see page 8)
Those are all of my questions. You do qualify for a telephone interview and we would like to invite you to join us on _______ at ______ PM. The discussion will last about 45 minutes; it will be recorded (audio only) to be sure we get all the information. In appreciation for your time, $40 gift card will be mailed to you after the interview.
Are you willing to participate?
01 yes
02 no
Prior to the start of the group discussion, you will receive an information sheet with such information as sponsorship of the study and contacts for more information. If after we hang up, you have a question about this group discussion or decide you can’t participate, please feel free to contact me. I’d be happy to answer your questions. My contact information at work is ________________.
Name_________________________________________________________________
Address________________________________________________________________
City/State/Zip___________________________________________________________
Day Number_________________________Night Number_____________________
Criteria include the following:
Own and use a computer, laptop, tablet or mobile device with internet access (iPhone/iPad, Android device)
Are willing to participate in the following activities:
Download or use the tool on their device
Use the tool before participating in the online discussion group (at least once a week prior to discussion group [up to two hours])
Will bring their device (if mobile) to the discussion group
Public reporting of this collection of information is estimated to average 10 minutes per response, including
the time for reviewing instructions and completing and reviewing the collection of information. An agency many not
conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current
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: PRA (XXXX-XXXX)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Wilburn, Ben |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |