Interview Screener - Refusal

Attachment D Screener and Baseline Interviewer Guide for Individuals Responding to Initial Phone Call Who Refuse to be screened

Form Approved

OMB No: 0920-1005

Exp. Date: xx-xx-xxxx

Public Reporting burden of this collection of information is estimated at 1 minute 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 (0920-1005).

INTRODUCTORY TEXT

[Screening interview - SCRIPT IF SOMEONE ANSWERS THE PHONE:]

Hello, my name is [INTERVIEWER NAME] from Battelle, a research organization that is working with the Centers for Disease Control and Prevention or CDC. We’re working on a study of how people who are age 60 or older plan for their future health. The results of this research will be used to provide information to other older adults to help them stay healthy. We’re looking for people to participate in a brief phone survey that will ask about your plans to protect your health over time. If you are interested, I will ask you a few questions to determine if you are eligible for the study. Your participation is completely voluntary, and all the information you provide will be kept private and secure. May we begin?

INTERVIEWER INSTRUCTION: IF NOT WILLING TO PARTICIPATE OR PARTICIPANT DOES NOT SPEAK ENGLISH. THANK THEM AND END CALL.

[VOICE MAIL SCRIPT IF NO ONE ANSWERS THE PHONE:]

Hi, my name is [INTERVIEWER NAME] from Battelle, a research organization that is working with the Centers for Disease Control and Prevention or CDC. We’re looking for people age 60 or older to participate in a brief phone survey that asks about their plans to protect their future health. If you are interested, please contact our research office at XXX-XXX-XXXX for more information. Thank you and we look forward to hearing from you soon.