Form 2 Claimant Screener Script Survey 1(participate)

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

Attachment 8_Claimant Screener Script Survey 1

Survey 1 - Screener Call (Participate/Eligible)

OMB: 0925-0704

Document [pdf]
Download: pdf | pdf
OMB	
  No.:	
  0925-­‐XXXX	
  
Expiration	
  Date:	
  XX/XX/2017	
  
Survey	
  1	
  –	
  Claimant	
  Screener	
  	
  
S1.	
  

Hello,	
  may	
  I	
  speak	
  with	
  (CLAIMANT	
  (IF	
  NEEDED:	
  I	
  am	
  trying	
  to	
  reach	
  the	
  person	
  who	
  recently	
  
received	
  a	
  letter	
  from	
  the	
  SSA	
  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	
  
NOT	
  AVAILABLE	
  ....................................................	
  	
   2	
  

(GO	
  TO	
  INTRO1)	
  
(SET	
  CALLBACK)	
  

	
  
[INTRO1]	
  
	
  
Hello,	
  this	
  is	
  (INTERVIEWER)	
  and	
  I’m	
  calling	
  from	
  Westat	
  about	
  a	
  Social	
  Security	
  Administration	
  (SSA)	
  
research	
  study.	
  	
  The	
  National	
  Institutes	
  of	
  Health	
  and	
  Boston	
  University	
  are	
  doing	
  this	
  study	
  and	
  Westat	
  
is	
  supporting	
  them.	
  	
  We	
  recently	
  sent	
  you	
  a	
  letter	
  about	
  the	
  study.	
  	
  	
  I	
  am	
  calling	
  now	
  to	
  invite	
  you	
  to	
  
participate	
  in	
  the	
  study.	
  	
  	
  	
  
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	
  the	
  next	
  few	
  questions	
  will	
  take.	
  	
  	
  
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.	
  
First,	
  are	
  you	
  age	
  21	
  or	
  older?	
  
	
  
YES	
  .......................................................................	
  	
  
NO	
  ........................................................................	
  	
  
REFUSE	
  .................................................................	
  	
  
DON’T	
  KNOW	
  .......................................................	
  	
  
	
  

1	
  
2	
  
7	
  
8	
  

(GO	
  TO	
  S3)	
  
(GO	
  TO	
  THANK1)	
  
(GO	
  TO	
  THANK1)	
  
(GO	
  TO	
  THANK1)	
  
1	
  

Version	
  6	
  
6/26/14	
  

S3.	
  

You	
  recently	
  filed	
  an	
  application	
  for	
  work	
  disability	
  with	
  the	
  Social	
  Security	
  Administration,	
  is	
  
that	
  correct?	
  

	
  
YES	
  .......................................................................	
  	
  
NO	
  ........................................................................	
  	
  
REFUSE	
  .................................................................	
  	
  
DON’T	
  KNOW	
  .......................................................	
  	
  

1	
  
2	
  
7	
  
8	
  

(GO	
  TO	
  INTRO2)	
  
(GO	
  TO	
  THANK1)	
  
(GO	
  TO	
  THANK1)	
  
(GO	
  TO	
  THANK1)	
  

	
  
[INTRO2]	
  
	
  
Now,	
  I	
  would	
  like	
  to	
  explain	
  to	
  you	
  a	
  little	
  more	
  about	
  taking	
  part	
  in	
  the	
  study.	
  	
  Please	
  listen	
  carefully.	
  	
  I	
  
will	
  be	
  asking	
  you	
  a	
  few	
  questions	
  afterwards	
  to	
  make	
  sure	
  you	
  understand.	
  	
  	
  
First,	
  your	
  decision	
  to	
  take	
  part	
  in	
  the	
  study	
  is	
  voluntary	
  and	
  completely	
  up	
  to	
  you.	
  	
  We	
  randomly	
  chose	
  
you	
  from	
  a	
  large	
  group	
  of	
  people	
  who	
  applied	
  for	
  social	
  security	
  disability	
  benefits	
  in	
  the	
  last	
  couple	
  of	
  
months.	
  	
  However,	
  this	
  study	
  has	
  nothing	
  to	
  do	
  with	
  your	
  disability	
  claim	
  and	
  your	
  claim	
  will	
  not	
  be	
  
affected	
  by	
  your	
  decision	
  to	
  take	
  part	
  in	
  the	
  study.	
  	
  SSA	
  staff	
  involved	
  in	
  the	
  disability	
  determination	
  
process	
  will	
  not	
  even	
  know	
  if	
  you	
  take	
  part	
  in	
  this	
  study.	
  	
  We	
  will	
  ask	
  you	
  to	
  complete	
  2	
  surveys.	
  Survey	
  
1	
  can	
  be	
  completed	
  during	
  this	
  call	
  or	
  at	
  later	
  time	
  convenient	
  to	
  you.	
  	
  You	
  may	
  decide	
  to	
  do	
  Survey	
  1	
  on	
  
your	
  own	
  over	
  the	
  internet	
  or	
  with	
  me	
  on	
  the	
  telephone.	
  	
  After	
  you	
  complete	
  Survey	
  1,	
  you	
  will	
  receive	
  
a	
  check	
  for	
  $20	
  for	
  your	
  time.	
  	
  We	
  will	
  call	
  you	
  about	
  10	
  days	
  after	
  you	
  finish	
  Survey	
  1	
  to	
  invite	
  you	
  to	
  
complete	
  Survey	
  2.	
  You	
  may	
  also	
  decide	
  to	
  do	
  Survey	
  2	
  on	
  your	
  own	
  over	
  the	
  internet	
  or	
  with	
  an	
  
interviewer	
  on	
  the	
  telephone.	
  	
  After	
  you	
  complete	
  Survey	
  2,	
  you	
  will	
  receive	
  an	
  additional	
  check	
  for	
  $30	
  
for	
  your	
  time.	
  	
  	
  
I	
  also	
  need	
  to	
  tell	
  you	
  about	
  some	
  possible	
  risks,	
  if	
  you	
  decide	
  to	
  take	
  part	
  in	
  the	
  study.	
  	
  	
  First,	
  it	
  is	
  
possible	
  that	
  some	
  of	
  the	
  questions	
  we	
  ask	
  may	
  upset	
  you.	
  	
  We	
  are	
  asking	
  questions	
  about	
  your	
  
functioning	
  (activities)	
  and	
  you	
  might	
  find	
  some	
  of	
  those	
  embarrassing	
  or	
  they	
  may	
  hurt	
  your	
  
feelings.	
  	
  You	
  do	
  not	
  have	
  to	
  answer	
  any	
  question	
  that	
  you	
  do	
  not	
  want	
  to	
  answer,	
  and	
  you	
  can	
  stop	
  
answering	
  questions	
  at	
  any	
  time.	
  	
  In	
  addition,	
  we	
  will	
  keep	
  your	
  contact	
  information,	
  such	
  as	
  your	
  name,	
  
address,	
  phone	
  number	
  and	
  email	
  address	
  secure	
  to	
  the	
  fullest	
  extent	
  of	
  the	
  law.	
  	
  However,	
  there	
  is	
  
always	
  a	
  small	
  risk	
  of	
  loss	
  of	
  privacy.	
  We	
  go	
  to	
  great	
  lengths	
  to	
  keep	
  your	
  information	
  private.	
  	
  Finally,	
  
there	
  is	
  little	
  physical	
  risk	
  involved	
  with	
  taking	
  part	
  in	
  this	
  study.	
  	
  However,	
  answering	
  the	
  questions	
  
could	
  make	
  you	
  tired.	
  	
  
Now,	
  I	
  would	
  like	
  to	
  ask	
  just	
  a	
  few	
  questions	
  to	
  see	
  if	
  you	
  can	
  take	
  part	
  in	
  the	
  study.	
  	
  	
  
	
  
S4.	
  
What	
  is	
  1	
  potential	
  risk	
  of	
  participating	
  in	
  this	
  study?	
  
(NOTE	
  TO	
  INTERVIEWER:	
  RESPONDENT	
  MUST	
  BE	
  ABLE	
  TO	
  PROVIDE	
  1	
  OF	
  THE	
  POSSIBLE	
  RESPONSES	
  
BELOW.)	
  
Possible	
  Responses:	
  	
  
2	
  
Version	
  6	
  
6/26/14	
  

•
•
•
•
•
•
•
•
•

The	
  questions	
  might	
  make	
  me	
  upset	
  (please	
  accept	
  any	
  synonym	
  for	
  this,	
  including	
  but	
  not	
  
limited	
  to:	
  sad;	
  cry;	
  mad;	
  angry;	
  unhappy)	
  	
  
The	
  study	
  won’t	
  affect	
  my	
  current	
  disability	
  application/claim	
  for	
  benefits	
  
Someone/SSA	
  might	
  find	
  out	
  who	
  I	
  am	
  
Someone/SSA	
  might	
  know	
  my	
  answers	
  came	
  from	
  me	
  
My	
  information	
  might	
  get	
  lost	
  
The	
  information	
  I	
  give	
  may	
  not	
  be	
  kept	
  secure/private/secret	
  
Someone	
  might	
  hack	
  into	
  my	
  information	
  
I	
  may	
  get	
  tired/sleepy/exhausted/drained/worn	
  out	
  
Little	
  risk	
  for	
  physical	
  discomfort/distress/concern/pain	
  
	
  
ACCURATE	
  ANSWER	
  ................................	
  	
   1	
  
INACCURATE	
  ANSWER	
  ............................	
  	
   2	
  
REFUSE	
  .......................................................	
  7	
  (GO	
  TO	
  THANK1)	
  
DON’T	
  KNOW	
  .............................................	
  8	
  (GO	
  TO	
  THANK1)	
  

	
  
S5.	
  

Name	
  1	
  thing	
  you	
  will	
  do	
  in	
  this	
  study?	
  	
  

(NOTE	
  TO	
  INTERVIEWER:	
  RESPONDENT	
  MUST	
  BE	
  ABLE	
  TO	
  PROVIDE	
  1	
  OF	
  THE	
  POSSIBLE	
  RESPONSES	
  
BELOW.)	
  
Possible	
  Responses:	
  	
  
• I	
  will	
  do	
  a	
  survey	
  
• I	
  will	
  do	
  2	
  surveys	
  /	
  I	
  will	
  answer	
  questions	
  2	
  times	
  (contact	
  frequency)	
  [THIS	
  SHOULD	
  BE	
  
COUNTED	
  AS	
  A	
  COMPLETE	
  CORRECT	
  RESPONSE.]	
  
• I	
  will	
  take	
  one	
  survey	
  now	
  (contact	
  frequency)	
  
• I	
  will	
  take	
  the	
  next	
  survey	
  in	
  10	
  days	
  (contact	
  frequency)	
  
• I	
  will	
  answer	
  questions	
  about	
  my	
  functioning/how	
  I	
  do	
  things/my	
  activities	
  (survey	
  content).	
  
• I	
  will	
  take	
  the	
  survey/answer	
  questions	
  over	
  the	
  internet/on-­‐line	
  by	
  myself	
  (administration	
  
mode).	
  
• I	
  will	
  take	
  the	
  survey/answer	
  questions	
  with	
  interviewer	
  over	
  the	
  telephone	
  (administration	
  
mode).	
  
	
  
ACCURATE	
  ANSWER	
  ................................	
  	
   1	
  
INACCURATE	
  ANSWER	
  ............................	
  	
   2	
  
REFUSE	
  .......................................................	
  7	
  (GO	
  TO	
  THANK1)	
  
DON’T	
  KNOW	
  .............................................	
  8	
  (GO	
  TO	
  THANK1)	
  
	
  
BOX	
  1	
  
IF	
  RESPONDENT	
  CORRECTLY	
  DESCRIBES	
  1	
  RISK	
  AND	
  
1	
  ELEMENT	
  OF	
  PARTICIPATION	
  (S4=	
  1	
  AND	
  S5	
  =	
  1),	
  THEN	
  GO	
  TO	
  S6.	
  
OTHERWISE,	
  GO	
  TO	
  THANK1.	
  
	
  
	
  
3	
  
Version	
  6	
  
6/26/14	
  

S6.	
  

What	
  are	
  the	
  names	
  of	
  the	
  conditions	
  you	
  would	
  say	
  are	
  the	
  main	
  reasons	
  why	
  working	
  is	
  
difficult	
  for	
  you?	
  [LIST	
  UP	
  TO	
  3	
  ONLY]	
  

	
  
	
  
	
  

a.______________________________________	
  
b.______________________________________	
  
c.______________________________________	
  
REFUSE	
  ..................................................................	
  7	
   	
  
DON’T	
  KNOW	
  ........................................................	
  8	
  

	
  
	
  
S7.	
  

CLAIMANT	
  CONSENT:	
  	
  Let	
  me	
  review	
  the	
  consent	
  form	
  that	
  we	
  sent	
  to	
  you	
  in	
  the	
  mail:	
  
	
  
Please	
  remember	
  that	
  it	
  is	
  your	
  choice	
  whether	
  to	
  participate	
  in	
  this	
  study.	
  	
  You	
  can	
  skip	
  any	
  
questions	
  that	
  you	
  do	
  not	
  want	
  to	
  answer.	
  	
  This	
  study	
  is	
  not	
  related	
  to	
  your	
  application	
  for	
  
benefits	
  and	
  whether	
  or	
  not	
  you	
  participate	
  will	
  not	
  affect	
  your	
  current	
  or	
  any	
  future	
  
application.	
  	
  If	
  you	
  do	
  participate,	
  please	
  realize	
  that	
  you	
  do	
  not	
  give	
  up	
  any	
  of	
  your	
  legal	
  
rights.	
  	
  If	
  you	
  withdraw	
  from	
  the	
  study	
  at	
  any	
  time	
  it	
  will	
  not	
  affect	
  you	
  in	
  any	
  way.	
  	
  Nothing	
  in	
  
the	
  study	
  will	
  directly	
  benefit	
  you.	
  	
  Hopefully,	
  it	
  will	
  benefit	
  future	
  applicants.	
  	
  	
  
Survey	
  1	
  takes	
  about	
  45-­‐60	
  minutes	
  and	
  Survey	
  2	
  will	
  take	
  about	
  30-­‐45	
  minutes.	
  	
  You	
  may	
  
obtain	
  further	
  information	
  about	
  your	
  rights	
  as	
  a	
  research	
  participant	
  by	
  calling	
  the	
  Office	
  of	
  the	
  
Institutional	
  Review	
  Board	
  at	
  Boston	
  University	
  or	
  the	
  investigator	
  in	
  charge	
  of	
  the	
  study.	
  	
  Their	
  
contact	
  information	
  is	
  on	
  the	
  copy	
  of	
  the	
  consent	
  form	
  we	
  mailed	
  to	
  you.	
  
Do	
  you	
  wish	
  to	
  participate	
  in	
  the	
  study?	
  
	
  
YES	
  .........................................................................	
  1	
  
NO	
  .........................................................................	
  2	
  (GO	
  TO	
  THANK1)	
  

	
  
	
  
S8.	
  

You	
  have	
  the	
  option	
  of	
  doing	
  the	
  survey	
  now	
  with	
  me	
  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?	
  

	
  

S9.	
  
	
  

INTERNET	
  ..............................................	
  	
   1	
   (GO	
  TO	
  S9)	
  
TELEPHONE	
  NOW	
  ..................................	
  	
   2	
   (GO	
  TO	
  WEB	
  SURVEY)	
  
TELEPHONE	
  LATER	
  ................................	
  	
   2	
   (GO	
  TO	
  APPT	
  SCREEN;	
  THEN	
  THANK2)	
  
	
  
	
  
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.]	
  

	
  
4	
  
Version	
  6	
  
6/26/14	
  

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.	
  

5	
  
Version	
  6	
  
6/26/14	
  


File Typeapplication/pdf
File TitleMicrosoft Word - Attachment 9_Claimant Screener Script Survey 080814.docx
File Modified2014-08-11
File Created2014-08-11

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