Att. H_Screener Script Guide

Attachment H - Screener

Form Approved

OMB No.: 0920-xxxx

Expiration Date: XX/XX/XXXX

Public Reporting burden of this collection of information is estimated at 10 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-XXXX).

Update the Height Recommendation for Proper Seat Belt Fit among Children

Project Number: 6201.34

Recruitment Screener Guide – CHILD PARTICIPANT

(Completed by adult guardian)

Date: ______________________

Thank you for your interest in our study. First, I would like to tell you a little bit about the study and if you are still interested, I will need to get some information from you.

Westat will be conducting the study for the Centers for Disease Control and Prevention (CDC). The session will take about 2 hours and will take place at ______________ (fill in location). As part of this study, we are trying to update the current height recommendations for when a child can safely transition from being buckled in a booster seat to being buckled the vehicle’s seat belt without a booster seat while traveling in a car. Your child will need no special knowledge or ability to participate. As part of the study, we will take various measurements, such as your child’s sitting and standing height, leg length, weight, etc. We will also measure how well the seat belt fits your child in a small selection of vehicles and seating positions. This will require your child to sit still while a trained researcher takes a number of measurements of the child in order to assess how well the seat belt fits when the child is using a booster seat and when they are only using a seat belt in the vehicle seat. It is important that you know that the researcher will have physical contact with your child in order to take the measurements. For example, to measure the seat belt fit we will need to measure the location of the hipbone and the shoulder, which may require a researcher to feel for the appropriate locations. The parent/guardian will be asked to be present at all times. At no time during the measurements will the vehicles be in motion, the ignition will be off and the vehicle will be stationary. Your child will be paid $50 for his/her completion of the study.

We will not be scheduling you for a session today. We need to get a group of available children together before we try to schedule a session. If your child is eligible, we will add his/her name to the list of potential participants.

NOTE: If parent/guardian has multiple children, complete a screener for each child. Keep screener forms together so that households with multiple child participants can be scheduled at the same time.

If you are interested, I will need to ask you a few questions to determine if your child is eligible. Are you interested in participating?

a. Yes (If yes, proceed).

b. No (If no, thank the person for their time and end the screener).

1. What is your Full Name? _________________________

2. What is your Child’s Full Name? _________________________

3. How old is [INSERT child’s first NAME from Q2]? _________________________

4. When is [INSERT child’s first NAME from Q2]’s birthdate? _________________________

5. What grade in school is [INSERT child’s first NAME from Q2] in? _________________________

6. Is [INSERT child’s first NAME from Q2] a male or female?

a. Male OR b. Female

7. Is [INSERT child’s first NAME from Q2] of Hispanic or Latino origin?

a. Yes b. No

8. Please indicate all that apply to [INSERT child’s first NAME from Q2]:

[Circle all that apply]

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or other Pacific Islander

5. White/Caucasian

1. How do you usually buckle up [INSERT child’s first NAME from Q2] while riding in a passenger vehicle (car, van, SUV, or pick-up truck)?

1. Backless Booster seat with seatbelt

2. Highback Booster seat with seatbelt

3. Seatbelt

4. This child is not usually buckled up

5. Don’t know

If parent is unclear of the difference between a backless booster and a highback booster, please provide the following description for clarity purposes:

• A Highback Booster is a booster seat with back and head support which goes up past the child’s ears. In this seat, the child’s back is against a back support instead of the vehicle’s seat back. Highback boosters usually have adjustable head rests and may also have side cushions/support to help hold the child in the seat.

• A Backless booster is a specialized cushion that the child sits on, instead of the vehicle seat. Backless boosters do not have a back; instead the child’s back rests against the back of the vehicle seat.

9.  DURING THE PAST 30 DAYS, how often did [INSERT child’s first NAME from Q2] sit in the front seat of the vehicle?

   1. Always

   2. Most of the time

   3. Sometimes

   4. Rarely

   5. Never

9.  Why does [INSERT child’s first NAME from Q2] use this [INSERT restraint type from Q9]? (open-ended)

9. Does [INSERT child’s first NAME from Q2] ever complain that s/he is uncomfortable in their [INSERT restraint type from Q9]?

   1. Always

   2. Most of the time

   3. Sometimes

   4. Rarely

   5. Never

9. [ASK IF Q12=a, b, c, d] What part of [INSERT child’s first NAME from Q2]’s body does s/he usually say is uncomfortable?

9. How strongly do you agree or disagree with the following sentence:

[INSERT child’s first NAME from Q2]’s comfort is the most important factor in choosing how to buckle him/her?

1. Strongly Agree

2. Agree

3. Neutral

4. Disagree

5. Strongly Disagree

9. Do you do anything to improve [INSERT NAME from Q2]’s comfort when s/he buckles up?  (open-ended)

Now, I will ask about [INSERT child’s first NAME from Q2]’s height and weight. If you do not have this information readily available, we will ask you to provide us with your best guess. If you are unable to provide an estimate of [INSERT child’s first NAME from Q2]’s height and weight, we will need to reschedule the call for when you have the information available. Are you prepared to provide this information?

a. Yes (If yes, complete rest of form starting at question 9).

b. No (If no, set up a time to reschedule and skip to question 10).

9. Can you please provide me with [INSERT child’s first NAME from Q2]’s approximate height and weight?

Height: ______ feet ________ inches

Weight: ______ lbs.

9. At [INSERT child’s first NAME from Q2]’s last well visit with their doctor, do you remember the doctor mentioning [INSERT child’s first NAME from Q2]’s BMI (body mass index)?

a. Yes b. No

If so, did the doctor counsel you on a high or low BMI?

a. Yes b. No

9. Can you tell me a phone number where we can easily contact you?

Home: ______________________________________________________

Cell: ________________________________________________________

9. Email Address:

______________________________________________________________

9. Home Address (including City and State):

____________________________________________________________________

9. How did you hear about the study?

1. Newspaper

2. Friend

3. Email

4. Craig’s List

5. Flyer

6. Other ___________________________

9. Can you tell me which days of the week and times you and your child might be available, if your child is selected to participate?

__________________________________________________________________

__________________________________________________________________

Closing:

Thank you for your time and interest. Once we get a pool of names together, we will schedule the session. We cannot guarantee that your child will be included in the study, but we will make every effort to include your child.

Thank you for your time. If you have any questions, you can reach us at ____________ (provide the phone number of the person who is screening). In addition, if you know anyone else who might be interested in participating, please pass on the contact information to him/her.

Hang up phone.