Cognitive Interview Participant Telephone Screener – NSP
Questionnaire Design
ID Number: ___________________
Contact Date: _________________
Hello, I’m _____________ from the Census Bureau. Thank you for contacting us about participating in our research study for the National Survey of Psychiatrists. I have a few questions that I would like to ask you to gather some information to see if you qualify for our study.
What is your name?
First name: _____________________________
Last name: _____________________________
(Ask if not obvious) Are you male or female?
o Male
o Female
Now I just need to get some background information.
In what year were you born? __________________________
Are you of Hispanic, Latino, or Spanish origin?
o Yes
o No
What is your race? Please select one or more of the following: White, Black or African American, American Indian or Alaska Native, Asian, or Native Hawaiian or other Pacific Islander?
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander
Which of the following best describes your work experience in psychiatry?
o I’m currently providing direct clinical care as a psychiatrist. (SKIP to Question 7)
o I’m not currently providing direct clinical care as a psychiatrist but I have within the past 2 years.
o I have not provided direct clinical care as a psychiatrist within the past 2 years.
o I have never provided direct clinical care as a psychiatrist.
6a. Are you currently employed?
o Yes
o No (SKIP to Question 9)
What is your current job title or job description? ______________________________________________________
Are you employed by the Federal Government? (if federal contractor, mark NO)
o Yes
o No
In what city, state, and ZIP code do you currently live?
City: ______________________________ State: ________________ Zip: ________________
How did you hear about this research opportunity?
E-mail link
Census Bureau employee
Friend or family member (but not a Census Bureau employee)
Google advertisement
Flyer
Other – specify:________________________________________
Have you participated in any research studies with the U.S. Census Bureau?
o Yes
o No
What is your daytime telephone number in case we need to contact you? __________________________________
What is the e-mail address we should use when following up, such as interview information or directions if you’re selected to participate? __________________________________________________________________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Slight changes to participate |
| Author | Dawn V Nelson |
| File Modified | 0000-00-00 |
| File Created | 2021-01-20 |