OMB No. 0930-0196
Expiration Date: 09/30/2016
Attachment B
Wellness Focus Group Screening and Recruitment Questionnaire
Public Burden Statement: 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 Office of Management and Budget (OMB) control number. The OMB control number for this project is 0930-0196. The public reporting burden for this collection of information is estimated to average 0.8 minute per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Substance Abuse and Mental Health Services Administration (SAMHSA) Reports Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland 20857.
WELLNESS FOCUS GROUP SCREENING AND RECRUITMENT QUESTIONNAIRE
Target Audiences: Screening and Recruitment Criteria
Four groups in the Washington, DC (WDC), metropolitan area (WDC, Maryland, and Virginia market)
Forty participants representing the four major racial/ethnic groups in the United States:
Ten Whites
Ten African-Americans (Blacks)
Ten Hispanics/Latinos (mix of countries of origin)
Ten Asians
Mix of individuals with the following characteristics:
Mix of males and females
Mix of ages from 18 to 65
Mix of educational levels
Mix of income levels
Participants’ segmentation:
Individuals in recovery (substance misuse) (two)
Individuals in recovery (mental health) (two)
Individuals in the general population (two)—Include family members/loved ones of people in recovery (two); community health providers servicing people in recovery (two)
Wellness Focus Group Screening and Recruitment Questionnaire
Wellness Materials Concept Testing
For each group, recruit 12 participants, in anticipation of 10 to show.
PARTICIPANTS’ SELECTION CRITERIA
Recruit:
An equal number of men and women
A mix of individuals in recovery, including recovery from substance misuse, mental disorders, or co-occurring disorders
A mix of family members and loved ones/friends of someone in recovery
A mix of providers of community-based organizations, nongovernmental organizations, and/or faith-based organizations that are servicing people in recovery and their families
Individuals from the general population
A mix of ages, from 18 to 65 years old
A mix of income levels
A mix of educational levels
A mix of Spanish-dominant participants with different countries of origin (attempt a mix)
Each group needs a mix of the following segments (per quotas listed below; see Table 1):
Individuals in recovery (substance misuse) (two)
Individuals in recovery (mental health) (two)
Individuals in the general population (two)
Family members/loved ones of people in recovery (two)
Community health providers servicing people in recovery (two)
Additionally, each group needs an overall mix of the following (quotas listed below; see Table 1):
Mix of males and females
Mix of racial/ethnic groups
Mix of educational levels
Mix of income levels
EXCLUSION CRITERIA
Individuals younger than 18 and older than 65 years old
Community health providers working in areas other than prevention or recovery from mental and/or substance use disorders
(For the English groups) Individuals who are unable to read and write in English
(For the Spanish groups) Individuals who are unable to read and write in Spanish
Individuals who do not speak English or Spanish
Individuals living outside the WDC metropolitan area.
Recruitment Objectives
Recruit 12 individuals (to get 10 participants per group). Individuals are willing and available to participate in a focus group session of 90 minutes, at evening hours.
Tentative dates for conducting the focus groups are:
January 2017, between 6:00 p.m. and 9:00 p.m.
TABLE 1. PARTICIPANTS’ QUOTA DISTRIBUTION
|
Focus Group 1 |
Focus Group 2 |
Focus Group 3 |
Focus Group 4 |
TOTAL |
|
|
|
|
|
|
|
WDC Metro Area, Group 1 |
WDC Metro Area, Group 2 |
WDC Metro Area, Group 3 |
WDC Metro Area, Group 4 |
4 |
GENDER |
|
|
|
|
|
Female |
5 |
5 |
5 |
5 |
20 |
Male |
5 |
5 |
5 |
5 |
20 |
PARTICIPANTS’ SEGMENTATION |
|
|
|
|
|
Individuals in recovery (substance misuse) |
2 |
2 |
2 |
2 |
8 |
Individuals in recovery (mental health) |
2 |
2 |
2 |
2 |
8 |
Individuals in the general population Family members/loved ones of people in recovery Community health providers servicing people in recovery |
2
2
2 |
2
2
2 |
2
2
2 |
2
2
2 |
8
8
8 |
RACIAL/ETHNIC GROUPS |
|
|
|
|
|
AI, AN, NH, PI1 |
1 |
1 |
1 |
1 |
4 |
Asian |
10 |
|
|
|
10 |
African-American/Black |
|
10 |
|
|
10 |
White |
|
|
10 |
|
10 |
Hispanic/Latino2 |
|
|
|
10 |
10 |
EDUCATION |
|
|
|
|
|
No high school diploma, no General Educational Development test |
1 |
1 |
1 |
1 |
4 |
High school graduate |
2 |
2 |
2 |
2 |
8 |
Some college or technical school |
3 |
3 |
3 |
3 |
12 |
College/technical school graduate |
3 |
3 |
3 |
3 |
12 |
Postgraduate |
1 |
1 |
1 |
1 |
4 |
LANGUAGE |
|
|
|
|
|
English—dominant |
10 |
10 |
10 |
|
30 |
Spanish—dominant |
|
|
|
10 |
10 |
INCOME |
|
|
|
|
|
|
Attempt a mix of income levels per group. |
||||
AGE |
|
|
|
|
|
18–28 |
2 |
2 |
2 |
2 |
8 |
29–39 |
2 |
2 |
2 |
2 |
8 |
40–50 |
2 |
2 |
2 |
2 |
8 |
51–60 |
2 |
2 |
2 |
2 |
8 |
61 plus |
2 |
2 |
2 |
2 |
8 |
|
|||||
SCREENING QUESTIONNAIRE
Hello. My name is ___________________. I work at _____ (organization’s name).
We’re interested in exploring your opinions, suggestions, and concerns related to new materials for the Wellness Initiative. We are beginning development of this product, and we want your help reviewing some of the concepts we’re considering. Your feedback will help us to produce materials that are more relevant and appealing for our target populations.
Are you interested in participating in this group session?
⃝ Yes
⃝ No [If No, terminate: “Thank you very much for your time. Have a good day/evening, good-bye.”]
Are you available to participate in a 90-minute session during the week of
[January 2017, in the Washington, DC, metropolitan area]?
⃝ Yes
⃝ No [If No, terminate: “Based on your availability, we cannot include you this time. Thank you for your interest.”]
Gender [Attempt to recruit an equal number of males and females.]
⃝ Female
⃝ Male
Recruiter: I’m going to ask you some questions that will indicate whether you qualify to participate in this discussion group.
Please let me know which one applies:
[Recruit 12 individuals for each group and a mix of at least the following categories.]
⃝ I am a person in recovery.
⃝ I am a family member/caregiver, loved one/friend of someone in recovery.
⃝ I am a provider working in a community-based organization, a nongovernmental organization, the faith-based community, etc., servicing people in recovery and/or their families.
⃝ I am a person from the general population.
⃝ Other, please explain.
Age [Recruit a mix; wait for response.]
⃝ 18–28
⃝ 29–39
⃝ 40–50
⃝ 51–60
⃝ 61 plus
[Record actual age ________.]
Are you of Hispanic, Latino, or Spanish origin?
⃝ Yes [CONTINUE]
⃝ No [CONTINUE]
What is your race? Select all that apply. [Do not read; wait for the response.]
⃝ American Indian/Alaska Native
⃝ Asian
⃝ Black/African-American
⃝ Native Hawaiian/Other Pacific Islander
⃝ White
Please select the option that best describes you:
⃝ I speak only English. [CONTINUE]
⃝ I am an English-dominant speaker. [CONTINUE]
⃝ I speak only Spanish. [CONTINUE]
⃝ I am a Spanish-dominant speaker. [CONTINUE]
⃝ I am bilingual in English and Spanish. [CONTINUE]
What is the highest degree or level of education you have completed?
⃝ No high school diploma; no General Educational Development test (GED)
⃝ High school graduate or GED
⃝ Some college or technical school
⃝ College/technical school graduate
⃝ Postgraduate
[Attempt to recruit participants with a mix of educational levels. Please refer to the quota for each city.]
Income [Recruit a mix; wait for response.]
⃝ Unemployed
⃝ $1,000–$20,000
⃝ $21,000–$45,000
⃝ $46,000–$70,000
⃝ $71,000–$100,000
⃝ $101,000–150,000
⃝ $151,000 and above
[Attempt to recruit participants with a mix of income levels.]
Recruiter: “Thank you for answering these questions. If you are selected as a group discussion participant, you will receive a call from me and/or an e-mail to confirm your participation and to be informed of the venue, date, and time of the group discussion session. Could you please provide us with information about the best way to contact you?”
Name: __________________________________________________________________
E-mail: ______________________________Phone/Mobile: _______________________
1 American Indian, Alaska Native, Native Hawaiian, other Pacific Islander. If any, replace this quota with another group.
2 See Spanish-dominant groups. Recruit a mix of countries of origin.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Luz Amparo Pinzon |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |