Form 1 screener

OMB #: 0925-XXXX
Expiration Date: XX/XX/XXXX

ATTACHMENT 5 – Screener (English/Spanish)

Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285a). Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private to the extent provided by law. Names and other identifiers will not appear in any report of the study. Information provided will be combined for all study participants and reported as summaries. You are being contacted by [face-to-face interview to complete this instrument so that we can better understand the diets and way of life of Native Americans, Hispanos, and non-Hispanic whites in New Mexico around the time of the Trinity nuclear test.

Public reporting burden for this collection of information is estimated to average 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-XXXX). Do not return the completed form to this address.

Screener to Recruit Hispanic/Latino non-Hispanic White and Native American Focus Group and Individual Interview Participants

Recruit up to 150 participants who are

• Hispanic/Latino, non-Hispanic White or Native American

• 70 years or older (Alive in 1945)

• Resided in New Mexico or on one of New Mexico’s tribal reservations (if Native American) during the 1940s and 1950s

• Ideally, helped to care for children in his or her community during the 1940s

Overall aim is to

• Recruit up to 120 participants for 10-15 focus groups of 6-8 participants each.

• Recruit up to 30 participants for individual interviews

• Aim for an even balance between Hispanic/Latino, non-Hispanic White and Native American interviews and focus groups

Note: The screening interview may be conducted in English or Spanish. Screening interviews with Native American persons who are more comfortable in their native language may be conducted with the help of an interpreter fluent in either English or Spanish and the interviewee’s native language.

SCREENER

Hola, soy ________________ de [nombre de compañía]. Estoy llamando de parte del Instituto Nacional del Cáncer (National Cancer Institute en inglés). El Instituto Nacional del Cáncer está realizando un estudio sobre estilo de vida y hábitos alimenticios de la gente en su comunidad durante los años 1940 —y quiere incluir su punto de vista. Necesito hacerle unas preguntas para saber si puedo invitarle a participar en una entrevista. Sus respuestas serán completamente confidenciales y privadas y no se compartirán con otros. Usted recibirá una pequeña compensación por su participación. Mis preguntas hoy solo requieren unos minutos.

¿Puedo continuar con mis preguntas?

Hello, I’m __________ from [name of firm]. I’m calling today on behalf of the National Cancer Institute, or NCI. NCI is conducting a research study about the lifestyle and dietary habits of people in your community during the 1940s—and would like to include your views. I need to ask you just a few questions to determine whether I can invite you to participate in an interview or group discussion Your responses will be completely confidential and private and not shared with others. You will receive a small honorarium for your time. My questions today will only take a couple of minutes.

May I continue with my questions?

BACKGROUND QUESTIONS

1. Es importante que hablemos con personas que eran niños en 1945. ¿Me puede decir su edad? / It’s important for us to speak to people that were alive in 1945. Can you tell me your age?

RECORD EXACT AGE_________

(IF OVER THE AGE OF 70, CONTINUE. OTHERWISE, TERMINATE.)

2. ¿Usted vivía en Nuevo Mexico durante los años 1940 y 1950? / During the 1940s and 1950s, were you living in New Mexico?

Sí / Yes_____

Terminate>> No _____

Terminate>> Refuse _____

3. ¿Se considera usted … / Do you consider yourself …

Hispano o Latino/ Hispanic or Latino?	Si/ Yes _____
Español / Spaniard	Si/ Yes _____
Native American/ Native American	Si/ Yes _____ >> Go to 6
Non-Hispanic White/ Non-Hispanic White	Si/ Yes _____ >> Go to 6
Otro/ Other	Si/ Yes _____ >>> Terminate
Refuse	>>> Go to 6

Hispano(a) o Latino(a) / Hispanic or Latino	Si/ Yes _____ No ______
India Americano(a) or Nativa de Alaska / American Indian or Alaska Native	Si/ Yes _____ >> Go to 6
Blanco(a) / White	Si/ Yes _____ >> Go to 6
Negro(a) o Africano(a) Americano(a) / Black or African American	Si/ Yes _____ >> If Yes and Hispanic is No, then Terminate
Asiático(a) / Asian	Si/ Yes _____ >> If Yes and Hispanic is No, then Terminate
Nativa de Hawaii o Otra de las islas Pacífico / Native Hawaiian or Other Pacific Islander	Si/ Yes _____ >> If Yes and Hispanic is No, then Terminate

4. ¿Cuál considera usted que es su país de origen? / Which do you consider you country of origin?

[Record country]____________________________________

IF THE ANSWER IS USA, PLEASE PROBE FURTHER BY ASKING:
¿Cuál es su origen o ascendencia Hispana? / Where does the Hispanic origin come from?

[Record country]____________________________________

5. ¿Prefiere, participar en una entrevista en español, en inglés, o en otro idioma? / Do you prefer to participate in the interview in Spanish, English, or another language?

Español / Spanish ____

Lo mismo - No hay preferencia de idioma / Either - No preference ____

Inglés / English ____

Otro idioma / Other language ____

[Record language]____________________________________________

6. [SOLO PREGUNTE SI #3=NO / ASK ONLY IF #3=NO] ¿Durante los años 1940 y 1950, vivía usted en un terreno indígena? / During the 1940s and 1950s, were you living on tribal land?

Sí / Yes_____

Terminate>> No _____

[Record living location] __________________________________________

7. ¿Durante los años 1940 y 1950, tuvo contacto diario con los niños? / During the 1940s or 1950s, did you have daily contact with children?

Sí / Yes_____

Terminate>> No _____

8. ¿Durante los años 1940 y 1950, ayudó a cuidar a los niños? / During the 1940s or 1950s, did you help to care for other children?

Sí / Yes_____

No _____

ATTEMPT TO RECRUIT AT LEAST SOME RESPONDENTS WITH EXPERIENCE CARING FOR CHILDREN. (THIS IS PREFERABLE, BUT NOT ESSENTIAL.)

DEMOGRAPHICS

9. ¿Cuál es su sexo? / What is your gender?

Female _____

Male _____

10. ¿Cuál es el nivel o grado de educación más alto que usted ha completado? / What is the highest level of education you have completed? [Attempt to recruit a balanced mix but it is not required]

Octavo grado o menos Less than high school _____

Algo de escuela secundaria (High School) Some high school_____

Graduado de escuela secundaria o escuela vocacional, GED High school or vocational school graduate GED _____

Algo de universidad Some college _____

Graduado de universidad College degree _____

Estudios o título posgraduado como una Maestría o un Doctorado Post Graduate degree _____

**TERMINATE LANGUAGE: Muchas gracias por su tiempo. No podremos incluirle en nuestro estudio. Gracias por su tiempo e interés. Que tenga un buen día / noche. / Thank you very much for your time. We’re not going to be able to include you in this study. Thank you for your time and interest. Have a good day/evening.

INVITE TO INTERVIEW

Gracias por responder a mis preguntas. Como le había mencionado, estas entrevistas se están llevando a cabo en nombre del Instituto Nacional del Cáncer para saber más sobre el estilo de vida y hábitos alimenticios de la gente en su comunidad durante los años 1940. Nos gustaría incluir sus puntos de vista.

Para que podamos conocer su experiencia y punto de vista, me gustaría invitarle a participar en una entrevista en persona. Cinco personas que trabajan para el Instituto Nacional del Cáncer estarán presentes durante la entrevista.

Thank you for answering my questions. As I mentioned this study is being conducted on behalf of the National Cancer Institute about lifestyle and dietary habits in your community in the 1940s and we’d like to be able to include your views.

In order for us to learn from your experience firsthand, I would like to invite you to participate in a group discussion or a one-on-one interview. Up to four people that work for the National Cancer Institute will be present during the interview.

TRANSPORATION AND LOGISTICS

11. Would you like to have the interview close to where you live? If so where?

[Record]____________________________________

12. Le animamos a traer a alguien a la entrevista que puede apoyarle. / We encourage you to bring someone to the interview who can support you.

¿Cuales personas lo acompañarán? Which people will accompany you?

[Record]____________________________________

13. ¿Usted necesitará cuidado de niños durante la entrevista ? / Will you need childcare during the interview?

Si/Yes _____

No _____

14. ¿Usted necesitará transportación para poder participar en la entrevista? / Will you need transportation so that you can participate in the interview?

Si/Yes _____

No _____

La entrevista durará una hora y media y se llevara acabo en _________. Tengo varios horarios disponibles en [FECHAS] para que podamos realizar la entrevista cuando sea conveniente para usted.

El propósito de la entrevista no es tratar de venderle algo. Tampoco le llamarán por teléfono una vez termine la entrevista para tratar de venderle algo. Para compensarle por su tiempo y los gastos de viaje, usted recibirá un certificado de $50 por llegar a la entrevista. ¿Podemos contar con su participación y coordinar el día y la hora de su entrevista?

The interview will last up to two hours and will take place at _______________. I have several time slots on [DATES], so we can conduct the interview when it’s convenient for you.

This is not a sales effort of any kind and no one will call on you as a result of your participation. To compensate you for your time and travel expenses, you will receive a gift certificate for $50 for coming to the interview. Can we schedule your participation?

Le enviaremos una carta de confirmación como recordatorio el día y la hora de la entrevista. También le llamaremos una semana antes y un día antes de la entrevista para recordarle. Como solamente estamos invitando a un pequeño número de personas, estaremos contando con su presencia. Es sumamente importante que la entrevista comience a tiempo. Si usted usa lentes o espejuelos, recuerde traerlos a la entrevista. Si por algún contratiempo le resulta imposible asistir a la entrevista, no mande a alguien en su lugar. Por favor llame a _________al número ________ e infórmenos. Anote el número por si lo necesita. Gracias.

We will send you a letter and we will also call you to remind you of the time and date. We will call you the week before and the day before to remind you. Since we are only inviting a select number of people, we will be counting on you to attend. If you wear reading glasses, please bring them with you. If for some reason you cannot come, do not send someone else in your place. Please call at . Please write the number down, in case you need it later. Thank you.

Check day and time; see details below

NAME: _________________________________________________

ADDRESS: _________________________________________________

CITY: _________________________________________________

ZIP CODE: _________________________________________________

PHONE: (DAY) _____________________________________

(EVE) _____________________________________

(CELL) _____________________________________

(EMAIL) _____________________________________

Interview Dates -TO BE DETERMINED

Interview Time Slots - Time slots for interviews with persons needing an interpreter in the same language should be arranged consecutively if possible.

DATE TBD 9:30 am 11:00 am 12:30 am 2:30 pm 4:00 pm 5:30 pm 6:45 pm [over-recruit]**

DATE TBD 9:00 am 10:30 am 12:00 am 2:00 pm 3:30 pm 5:00 pm 6:15 pm [over-recruit]**

DATE TBD 9:00 am 10:30 am 12:00 am 2:00 pm 3:30 pm 5:00 pm 6:15 pm [over-recruit]**

Table1. Current ages for recruitment and their age for recalling the 1940s and 1950s

Current age	Born	Age in 1945	Age in 1940	Age in 1950	Age in 1959
70	1945	0		5	14
71	1944	1		6	15
72	1943	2		7	16
73	1942	3		8	17
74	1941	4		9	18
75	1940	5	0	10	19
76	1939	6	1	11	20
77	1938	7	2	12	21
78	1937	8	3	13	22
79	1936	9	4	14	23
80	1935	10	5	15	24
81	1934	11	6	16	25
82	1933	12	7	17	26
83	1932	13	8	18	27
84	1931	14	9	19	28
85	1930	15	10	20	29
86	1929	16	11	21	30
87	1928	17	12	22	31
88	1927	18	13	23	32
89	1926	19	14	24	33
90	1925	20	15	25	34
91	1924	21	16	26	35
92	1923	22	17	27	36
93	1922	23	18	28	37
94	1921	24	19	29	38
95	1920	25	20	30	39
96	1919	26	21	31	40