Form 3 Survey 2 Claimant Screener script

Calibration II & Predictive Validity Testing of Item Response Theory – Computer Adaptive Testing Tools (IRT-CAT)

Attachment 9_Survey 2 screener

Survey 2 Screener Call (Not Interested)

OMB: 0925-0704

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OMB	
  No.:	
  0925-­‐XXXX	
  
Expiration	
  Date:	
  XX/XX/2017	
  

Survey	
  2	
  –Screener	
  
S1.	
  

Hello,	
  may	
  I	
  speak	
  with	
  (CLAIMANT	
  (IF	
  NEEDED:	
  I	
  am	
  trying	
  to	
  reach	
  the	
  person	
  who	
  recently	
  
received	
  a	
  letter	
  from	
  the	
  Social	
  Security	
  Administration	
  about	
  a	
  research	
  study))?	
  	
  

	
  
[IF	
  ASKED,	
  “WHO’S	
  CALLING?”]:	
  	
  
My	
  name	
  is	
  (DATA	
  COLLECTOR)	
  and	
  I	
  am	
  calling	
  from	
  Westat	
  about	
  a	
  Social	
  Security	
  
Administration	
  research	
  study.	
  	
  
	
  
	
  
YES/SPEAKING	
  .................................	
  	
  1	
   (GO	
  TO	
  INTRO1)	
  
NOT	
  AVAILABLE	
  ...............................	
  	
  2	
   (SET	
  CALLBACK)	
  
OTHER	
  (FINAL)	
  ................................	
  	
  3	
   (GO	
  TO	
  THANK1	
  AND	
  RECORD	
  FINAL	
  TRC	
  STATUS	
  CODE)	
  
NEW	
  PHONE	
  NUMBER	
  ....................	
  	
  4	
   (RECORD	
  NEW	
  PHONE	
  NUMBER)	
  
	
  
	
  
[INTRO1]	
  
	
  
Hello,	
  this	
  is	
  (INTERVIEWER)	
  and	
  I’m	
  calling	
  from	
  Westat	
  about	
  a	
  Social	
  Security	
  Administration	
  (SSA)	
  
research	
  study.	
  	
  We	
  spoke	
  to	
  you	
  about	
  a	
  week	
  ago.	
  	
  	
  Thank	
  you	
  for	
  your	
  participation	
  in	
  that	
  survey.	
  	
  
We	
  are	
  calling	
  back	
  now	
  to	
  see	
  if	
  you	
  are	
  able	
  to	
  take	
  part	
  in	
  the	
  second	
  survey.	
  	
  
	
  
Before	
  we	
  get	
  started,	
  I	
  am	
  required	
  to	
  read	
  to	
  you	
  a	
  statement	
  from	
  the	
  Office	
  of	
  Management	
  and	
  
Budget	
  (the	
  OMB).	
  	
  This	
  statement	
  will	
  provide	
  you	
  with	
  contact	
  information	
  should	
  you	
  have	
  questions	
  
or	
  comments	
  about	
  the	
  amount	
  of	
  time	
  it	
  will	
  take	
  to	
  answer	
  the	
  next	
  few	
  questions.	
  	
  	
  
OMB	
  No.:	
  0925-­‐XXXX	
  
Expiration	
  Date:	
  XX/XX/2017	
  	
  
Public	
   reporting	
   burden	
   for	
   this	
  collection	
   of	
   information	
   is	
   estimated	
  to	
  average	
   3-­‐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.	
   	
   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	
  aspects	
  of	
  this	
  collection	
  of	
  information,	
  including	
  suggestions	
  for	
  
reducing	
   this	
   burden	
   to:	
   NIH,	
   Project	
   Clearance	
   Branch,	
   6705	
   Rockledge	
   Drive,	
   MSC	
   7974,	
   Bethesda,	
   MD	
   20892-­‐7974,	
  
ATTN:	
  PRA	
  (0925-­‐XXXX).	
  	
  	
  

	
  
I	
  appreciate	
  for	
  your	
  patience	
  as	
  I	
  read	
  that.	
  
	
  
	
  
S2.	
  
Now,	
  I	
  need	
  to	
  ask	
  a	
  couple	
  questions	
  to	
  make	
  sure	
  I	
  am	
  speaking	
  to	
  the	
  correct	
  person.	
  	
  When	
  
we	
  spoke	
  to	
  you	
  a	
  little	
  over	
  a	
  week	
  ago,	
  please	
  tell	
  me	
  if	
  you	
  took	
  that	
  survey	
  with	
  an	
  
interviewer	
  over	
  the	
  telephone	
  or	
  on	
  the	
  internet	
  by	
  yourself.	
  
[INTERVIEWER:	
  CHECK	
  CLAIMANT’S	
  RESPONSE	
  AT	
  S2	
  WITH	
  THE	
  NOTES	
  IN	
  THE	
  CLAIMANT’S	
  
SCREENING	
  HISTORY	
  BOX	
  AT	
  THE	
  TOP	
  RIGHT	
  OF	
  THE	
  SCREEN].	
  
1	
  
Version	
  6	
  
8/8/14	
  

	
  
	
  
ACCURATE	
  RESPONSE	
  .................................................................	
  1	
  (GO	
  TO	
  INTRO2)	
  
INACCCURATE	
  RESPONSE	
  ..........................................................	
  2	
  (GO	
  TO	
  S3)	
  
REFUSE	
  ........................................................................................	
  7	
  (GO	
  TO	
  S3)	
  
DON’T	
  KNOW/DON’T	
  REMEMBER	
  ..............................................	
  8	
  (GO	
  TO	
  S3)	
  
	
  
	
  
S3.	
  

Please	
  confirm	
  your	
  date	
  of	
  birth?	
  
[INTERVIEWER:	
  CHECK	
  CLAIMANT’S	
  RESPONSEAT	
  S3	
  WITH	
  THE	
  DATE	
  OF	
  BIRTH	
  LISTED	
  AT	
  THE	
  
TOP	
  OF	
  THE	
  SCREEN].	
  

	
  
ACCURATE	
  RESPONSE	
  .................................................................	
  1	
  (GO	
  TO	
  INTRO2)	
  
INACCCURATE	
  RESPONSE	
  ..........................................................	
  2	
  (GO	
  TO	
  THANK1)	
  
REFUSE	
  ........................................................................................	
  7	
  (GO	
  TO	
  THANK1)	
  
DON’T	
  KNOW/DON’T	
  REMEMBER	
  ..............................................	
  8	
  (GO	
  TO	
  THANK1)	
  
	
  
	
  
	
  
[INTRO2]	
  
Thank	
  you	
  for	
  that	
  information.	
  	
  I	
  am	
  calling	
  today	
  to	
  invite	
  you	
  to	
  participate	
  in	
  the	
  second	
  survey	
  as	
  
part	
  of	
  the	
  SSA	
  Functional	
  Assessment	
  Study.	
  	
  This	
  survey	
  is	
  very	
  similar	
  to	
  the	
  first	
  one.	
  	
  It	
  will	
  take	
  
about	
  45	
  minutes	
  to	
  complete.	
  	
  After	
  you	
  complete	
  the	
  survey,	
  you	
  will	
  receive	
  a	
  check	
  for	
  $30	
  for	
  your	
  
time.	
  	
  
	
  
S4.	
  
Do	
  you	
  wish	
  to	
  continue	
  with	
  the	
  study?	
  
	
  
YES	
  .........................................................................	
  1	
  (GO	
  TO	
  S5)	
  
NO	
  .........................................................................	
  2	
  (GO	
  TO	
  THANK1)	
  
	
  
	
  
S5.	
  
You	
  have	
  the	
  option	
  of	
  doing	
  the	
  survey	
  now	
  over	
  the	
  telephone	
  or	
  I	
  can	
  schedule	
  the	
  interview	
  
for	
  a	
  different	
  time.	
  	
  You	
  can	
  also	
  go	
  on	
  the	
  Internet	
  to	
  complete	
  the	
  survey	
  on	
  your	
  own.	
  Which	
  
would	
  you	
  prefer?	
  
	
  
INTERNET	
  ..............................................	
  	
   1	
   (GO	
  TO	
  S6)	
  
TELEPHONE	
  NOW	
  ..................................	
  	
   2	
   (GO	
  TO	
  WEB	
  SURVEY)	
  
TELEPHONE	
  LATER	
  ................................	
  	
   2	
   (GO	
  TO	
  APPT	
  SCREEN;	
  THEN	
  THANK2)	
  
	
  
	
  
S6.	
  
We	
  will	
  send	
  you	
  an	
  email	
  with	
  details	
  and	
  instructions	
  for	
  logging	
  on	
  to	
  the	
  web	
  survey.	
  May	
  I	
  
please	
  have	
  your	
  email	
  address?	
  
	
  
[NOTE	
  TO	
  INTERVIEWER,	
  RESPONDENT	
  CAN	
  NOT	
  DO	
  SURVEY	
  ON	
  INTERNET	
  IF	
  THEY	
  DO	
  NOT	
  
HAVE	
  AN	
  EMAIL	
  ADDRESS	
  OR	
  REFUSE	
  TO	
  PROVIDE	
  AN	
  EMAIL	
  ADDRESS	
  FOR	
  US	
  TO	
  SEND	
  THE	
  
SURVEY	
  LINK.]	
  
	
  
2	
  
Version	
  6	
  
8/8/14	
  

	
  
	
  
THANK1.	
  
	
  
THANK2.	
  
	
  
THANK3.	
  

E-­‐MAIL	
  ADDRESS	
  ____________________________	
  
CONFIRM	
  E-­‐MAIL	
  ADDRESS	
  ____________________	
  	
  
	
  

(GO	
  TO	
  THANK3)	
  

Thank	
  you,	
  but	
  those	
  are	
  all	
  the	
  questions	
  I	
  have	
  for	
  you.	
  Good-­‐bye.	
  
Thank	
  you	
  for	
  taking	
  the	
  time	
  to	
  answer	
  these	
  questions.	
  We	
  look	
  forward	
  to	
  your	
  
participation	
  in	
  our	
  study.	
  
Thank	
  you	
  for	
  taking	
  the	
  time	
  to	
  answer	
  these	
  questions.	
  You	
  should	
  receive	
  an	
  email	
  
with	
  a	
  link	
  for	
  the	
  web	
  survey	
  soon.	
  We	
  look	
  forward	
  to	
  your	
  participation	
  in	
  our	
  study.	
  

	
  
	
  

3	
  
Version	
  6	
  
8/8/14	
  


File Typeapplication/pdf
File TitleMicrosoft Word - Attachment 8_Survey 2 screener_8.8.2014.V6.docx
File Modified2014-08-11
File Created2014-08-11

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