Screener

Form Approved

OMB No. 0920-1154

Exp. Date: 01/21/2020

CDC Alcohol Reframing Project

Alcohol in Society Screening Questionnaire

Part 1: Initial Email Screening Script

Project: Alcohol in Society

Format: 90-minute in-person discussions and Triad Discussions

You have been selected to complete a short survey. Based on your responses, we will be able to determine if you might qualify for this study.  If your responses are a match, someone from [RECRUITMENT FIRM] will contact you by phone to complete the screening process.  

All of your responses will be kept private.

LINK TO SURVEY

1. How old were you on your last birthday?

_____

Age 21 Or Over  CONTINUE Under Age 21 TERMINATE

[NEXT SCREEN—AUDIT]

Please click in one box to answer. Think about your drinking in the past year. A drink means one beer, one small glass of wine (5 oz.), or one mixed drink containing one shot (1.5 oz.) of spirits.

QUESTIONS	0	1	2	3	4	5	6	Score
1. How often do you have a drink containing alcohol?	Never	Less than Monthly	Monthly	Weekly	2-3 times a week	4-6 times a week	Daily
2. How many drinks containing alcohol do you have on a typical day you are drinking?	1 drink	2 drinks	3 drinks	4 drinks	5-6 drinks	7-9 drinks	10 or more drinks
3. How often do you have X (5 for men; 4 for women, 4 for women & men over age 65) or more drinks on one occasion?	Never	Less than Monthly	Monthly	Weekly	2-3 times a week	4-6 times a week	Daily
4. How often during the last year have you found that you were not able to stop drinking once you had started?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
5. How often during the past year have you failed to do what was expected of you because of drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
6. How often during the past year have you needed a drink first thing in the morning to get yourself going after a heavy drinking session?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
7. How often during the past year have you had a feeling of guilt or remorse after drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
8. How often during the past year have you been unable to remember what happened the night before because you had been drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
9. Have you or someone else been injured because of your drinking?	No		Yes, but not in the past year		Yes, during the past year
10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking and suggested you cut down?	No		Yes, but not in the past year		Yes, during the past year
							Total

Thank You for taking the time to answer our questions. Someone from [RECRUITMENT FIRM] may contact you to ask you a few more questions to see if you qualify. Please enter your contact information below.

Name: ________________________

Phone Number: ________________

Part 2: Phone Screening

Hello, my name is _______________ and I’m calling from the research firm called [name]. You recently completed an online survey for a study on alcohol in society sponsored by the Centers for Disease Control and Prevention, the CDC. The study will involve participating in an in-person interview or small group discussion that will be conducted by RTI International, an independent, nonprofit research organization. The discussion will take about 90 minutes and you will receive up to $60 in appreciation for your time.

To confirm your eligibility to participate in this research study, I need to ask you a few additional questions. All of your responses will be kept private.

May I proceed?

Yes  CONTINUE

No  END [Thank respondent and end call.]

1. How old were you on your last birthday?

_____

Age 21 Or Over  CONTINUE Under Age 21 TERMINATE Over Age 55 TERMINATE

2. What is your gender?

Male		 CONTINUE
Female		 CONTINUE
Other		_____________
SCREEN FOR APPROPRIATE GROUP

3. Are you Hispanic or Latino? (Monitor distribution to ensure we have diversity as close to U.S. distribution as possible.)

Yes		 CONTINUE
No		 CONTINUE
SCREEN FOR A MIX

4. Which of these groups best describes you? You may provide more than one answer. (Monitor distribution to ensure we have diversity as close to U.S. distribution as possible.)

White		 CONTINUE
Black/African American		 CONTINUE
American Indian or Alaska Native		 CONTINUE
Asian		 CONTINUE
Native Hawaiian or Pacific Islander		 CONTINUE
Other		 CONTINUE
Two or more races		 CONTINUE
SCREEN FOR A MIX

5. What is the highest level of education you have attained? (Monitor distribution to ensure we have some lower education participants as close to U.S. distribution as possible.)

Less than high school		 CONTINUE
High school graduate (or GED)		 CONTINUE
Some college or technical school (No degree)		 CONTINUE
College graduate (2- or 4-year degree)		 CONTINUE
Some graduate school (No degree)		 CONTINUE
Graduate school degree		 CONTINUE
SCREEN FOR A MIX OF THE FOLLOWING: 15% Less than HS degree [Will provide target numbers for each site] 30% HS degree 20% Some college 25% College degree 5% Graduate degree

6. Have you ever worked for …? [Read the options below.]

Department of Health and Human Services		 TERMINATE
Centers for Disease Control and Prevention		 TERMINATE
RTI International		 TERMINATE
A market research company		 TERMINATE
None of the above		 CONTINUE

Invitation for Eligible Participants

Thank you for answering all of my questions. We would like to invite you to take part in the study.

IF INTERVIEW:

IF TRIAD:

No one will attempt to sell you anything, and no one will call you for other studies as a result of your participation. In appreciation for your time, you will receive $60. This is an important research effort, and we hope that you will be part of it. I also want to let you know that the discussion will be audio recorded. The audio files will be shared only with the project team and will not include any identifying information.

Can we schedule your attendance?

Yes  CONTINUE

No  [Thank respondent and end call.]

OFFER AVAILABLE TIMES BASED ON WHICH SEGMENT PARTICIPANT IS ELIGIBLE FOR.

Closing for Ineligible Participants

I’m sorry, but you are not eligible for this study, but we thank you for your interest in this study and for taking the time to answer our questions today.

SEGMENT INFORMATION

Segments

Group 1* Female, At-Risk Drinkers	Group 2* Female, Not at Risk	Group 3 Male, At-Risk Drinkers	Group 4 Male, Not at Risk
Age 21–55 AUDIT score of 8-18	Age 21–55 AUDIT Score of 3–7	Age 21–55 AUDIT score of 8-18	Age 21–55 AUDIT score of 3-7

*Include some interviews/triads of women 21–44 (childbearing age).

Segmentation

	Group 1 Female, At-Risk Drinkers	Group 2 Female, Not at Risk	Group 3 Male, At-Risk Drinkers	Group 4 Male, Not at Risk
Interviews	5	4	5	4
Triads	3	3	3	3

Site Specific Breakdown

Phase 1. Descriptive

Site 1: Raleigh, North Carolina

• 5 interviews

• 3 triads

Site 2: St. Louis, Missouri

• 4 interviews

• 3 triads

Total: 9 interviews, 6 triads

Phase 2. Prescriptive

Site 3: Seattle, Washington

• 5 interviews

• 3 triads

Site 4: Raleigh, NC

• 4 interviews

• 3 triads

Total: 9 interviews, 6 triads

Total across sites = 18 interviews, 12 triads

Participant Information

NAME: ________________________________________________________

ADDRESS: ________________________________________________________

CITY: ________________________________________________________

ZIP CODE: ________________________________________________________

EMAIL ________________________________________________________

What is the best time to reach you? What is the best telephone number to reach you at that time?

BEST TIME TO BE REACHED: ________________________________________

BEST PHONE NUMBER: ______________

Is there another time and number we can try if we miss you?

ALTERNATE PHONE NUMBER:

Recruiter: ____________________

Public reporting burden of this collection of information is estimated to average 10 minutes, 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 NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-1154).