Pre-Screening Questionnaire 05JUL2016

Appendix D

Data Collection Pre-Screening Questionnaire

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

Data Collection Pre-Screening Questionnaire

Note to Screening Personnel

Read the following Introductory Statement, followed by the questionnaire if they agree to participate. Regardless of how contact is made, this questionnaire must be administered before a decision is made regarding suitability for this study.

Introductory Statement (Use the following script in italics as a guideline in the screening interview):

Hello! My name is _____ and I’m recruiting participants for a study to evaluate miners knowledge of mine site hazards. The first step is to determine your eligibility. If you are eligible, you will be asked to sign a consent form. Once you are qualified for the study, we will set up a time that works best for you to take part in the study. Would you like to participate?

If they agree:

Next, I’ll ask several questions to see if you are eligible to participate. Any information collected during this screening will be kept confidential. Do I have your permission to ask these questions?

If they do not agree:

Thanks for your time.

If they do agree:

Questions

1. Have you ever had radial keratotomy (laser eye surgery), or other eye surgeries?

Yes _____ (rejection). If yes, tell them “Thanks for your time but you are not eligible.”

No _____

2. Do you have normal vision or corrected to at least 20/40 vision?

Yes _____

No _____ (rejection). If no, tell them “Thanks for your time but you are not eligible.”

Public reporting burden of this collection of information 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 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

3. Do you have monocular vision?

Yes _____(rejection). If yes, tell them “Thanks for your time but you are not eligible.”

No _____

4. Do you have glaucoma?

Yes _____(rejection). If yes, tell them “Thanks for your time but you are not eligible.”

No _____

5. Do you have macular degeneration?

Yes _____(rejection). If yes, tell them “Thanks for your time but you are not eligible.”

No _____

6. Are you able to stand unassisted for 30 minutes?

Yes _____

No _____ (rejection). If no, tell them “Thanks for your time but you are not eligible.”

7. Do you use an assistive device to walk or stand?

Yes _____(rejection). If yes, tell them “Thanks for your time but you are not eligible.”

No _____

Screening Criteria for Participation:

1. No radial keratotomy (laser eye surgery), or other eye surgeries

2. No monocular vision

3. Normal or corrected to normal vision

4. Able to stand unassisted for 30 minutes

5. Able to walk unassisted

6. Consent to performing study

Screening Result:

Rejected _____

or

Accepted _____

If the subject is accepted, complete the following:

Subject Identification Number (ID) __________

What is your preferred time and day to participate in the study? This should require no more than 90 minutes.

Best date and time to participate in the study ____________________

Screening Personnel (print name): _______________________________ Date: __________