App D_Recruitment Phone Screener

Appendix D

Form Approved

OMB No. 0920-0822

Exp. Date: 6/30/2016

Public Reporting burden of this collection of information is estimated at 7 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 Phone Screener

DATE: ______/ ________/ ________

USE IF SOMEONE IS CALLING IN TO RTI TO DETERMINE ELIGIBILITY

Hello, my name is ________. Thank you for your interest in participating in our study. RTI 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, in order 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 would be one of 30 participants who help test this survey by participating in a 1 to 2 hour in-person interview. You must be able to attend an interview in-person within 120 miles of Raleigh/Durham/Chapel Hill, NC. If you complete the in-person interview you will receive $40 in cash upon completion of the interview.

In order to determine your eligibility, I just need to ask you 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. May I have your age?

[IF RELUCTANT TO RESPOND ASK CATEGORIES BELOW]

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?

Flier……………………………………… 1 Where was flier posted? __________________________

Word-of-Mouth…………………… 2

Newspaper Advertisement….. 3 Which newspaper? _____________________________

Craigslist Advertisement 4

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 I’m going to ask you 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. Is it ok to continue with the questions?

If YES, go to #8

If no, “Unfortunately I need to ask these questions in order to determine your eligibility. If you change your mind about participating, please call me back. Thank you for your time.”

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

IF DOES NOT MEET THE ELIGIBILITY CRITERIA FOR REMAINING TYPES OF RESPONDENTS NEEDED:

NOT ELIGIBLE: I’m sorry but you have not met the criteria we are looking for. Thank you for calling.

IF MEETS THE ELIGIBILITY CRITERIA FOR REMAINING TYPES OF RESPONDENTS NEEDED:

ELIGIBLE: You are eligible to participate in an in-person interview at {SITE FILL}. This interview will take approximately 1-2 hours. We would like to audiotape the interview. The tape will only be heard by authorized people who are working on this project. The only purpose of recording is to allow us to review the interview in order to hear how well the survey questions work. We will destroy the recording at the end of the study. If at any time you would rather that the interview not be taped, just tell the interviewer and the interview will no longer be taped.

Would you be interested in participating?

YES………………. 1

NO……..………… 2 ---------- (END)

END: Thank you for your time.

I just need to collect some information for purposes of scheduling interviews. This information will NOT be connected to your answers provided during the interview.

11. May I have your first name? NAME:________________________________

12. May I have a telephone number where you can be contacted?

PHONE: (______)_______-_______

ALTERNATE PHONE: (______)_______-________

13. Will you be able to conduct the interview at {SITE FILL}?

IF YES, CONTINUE. IF NO, DISCUSS POSSIBLE ALTERNATIVE TRANSPORTATION ARRANGEMENTS TO RTI OR LOCATIONS FOR THE INTERVIEW WITH THE RESPONDENT AND CONTINUE.

Thank you. If you would like, we can schedule a time to complete the interview.

DETERMINE THE BEST TIME FOR THE RESPONDENT USING THE OUTLOOK CALENDER. IF THE INTERVIEW IS TO BE CONDUCTED AT THE RTI RTP OFFICE or REGIONAL OFFICE, PROVIDE DIRECTIONS.

Thank you. We look forward to meeting with you soon.

IF NECESSARY, LET THE RESPONDENT KNOW YOU WILL FOLLOW UP WITH ANY OUTSTANDING TRANSPORTATION OR MEETING LOCATIONS DETAILS.