Screener

Form Approved OMB No.: 0920-1154 Exp. Date: 1/31/2020

Reaching Minority Men Where They Are

Screener for focus groups with minority men with/at-risk for type-2 diabetes

Revised July 1, 2019

We are conducting a research study in which you may be eligible to participate. If you are interested, I will ask you some private questions regarding your medical history and present condition. You do not have to answer any question that you do not want to respond to, and you may end this screening at any time. All information collected today will be kept private. Your responses to this survey will be deleted if you decline to participate. If you choose to participate in this study, this survey will be kept with other research records for this study. These records are accessible to our research staff and will not be shared with anyone else without your permission.

CDC estimates the average public reporting burden for this collection of information as 3 minute per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-1154).

1. Are you interested in participating in this study?

• Yes

• No [terminate]

2. Do we have your permission to proceed in obtaining the confidential medical information about your medical history and present condition?

• Yes

• No [Terminate]

3. What is your sex?

• Male

• Female [Terminate]

4. Are you of Hispanic, Latino, or Spanish origin?

• Yes, of Hispanic, Latino, or Spanish origin

• No, not of Hispanic, Latino, or Spanish origin

5. What is your race? (Select all that apply)

• White

• Black or African American

• American Indian or Alaska Native

• Asian

• Native Hawaiian or Pacific Islander

Terminate if respondent selects “No” to #2 and Only “White” to #3

6. What is your age?

• Less than 18 years old [Terminate]

• 18 – 24

• 25 – 34

• 35 – 44

• 45 – 54

• 55 – 64

• 65 – 74

• 75 or older

7. Has a doctor or other health care provider ever told you that you have type 2 diabetes?

• Yes

• No

• I don’t know

Display if respondent does NOT select “Yes” to #5

8. Have you ever been told by a doctor or other health care provider that you have prediabetes or borderline diabetes?

• Yes

• No

• I don’t know

Display if respondent does NOT select “Yes” to #5

9. Have you ever been told by a doctor or other health professional that you had hypertension, also called high blood pressure?

• Yes

• No

• I don’t know

Display if respondent does NOT select “Yes” to #5

10. Has your mother, father, brother, or sister been diagnosed with type 2 diabetes?

• Yes

• No

• I don’t know

Display if respondent does NOT select “Yes” to #5

11. Do you usually engage in physical activity for at least 150 minutes (2.5 hours) per week? Physical activity is any activity that speeds up your heart rate and breathing, such as walking at a brisk pace, running, cycling, playing basketball, swimming, etc.

• Yes

• No

• I don’t know

Display if respondent does NOT select “Yes” to #5

12. How tall are you without shoes?

____ feet {accept integers 4 – 7}

____ inches {accept integers 0 - 11}

Display if respondent does NOT select “Yes” to #5

13. How much do you weigh without shoes?

____ pounds {accept integers 75 – 1000)

Qualified respondents:

1. Male, and

2. Minority race/ethnicity, and

3. Aged 18+

4. Disease status:

   1. Diagnosed with type-2 diabetes, or

   2. Diagnosed with prediabetes, or

   3. Diagnosed with hypertension, or

   4. Has a family history of type-2 diabetes, or

   5. Is physically inactive, or

   6. Aged 45 or older, or

   7. BMI >23 for Asian, BMI> 25 for all other races

Additional Screen-Out Questions:

1. Do you have experience in the market research or advertising industry?

• Yes (Terminate)

• No

2. Have you ever participated in focus groups?

• I have never participated in a focus group

• I have participated in one focus group

• I have participated in two or more focus groups (Terminate)

3. Are you a health care worker or clinician?

• Yes (Terminate)

• No

Additional Questions for Intra-group Diversity:

4. What is the highest grade or year of school you completed?

• Never attended school or only attended kindergarten

• Grades 1 through 8 (Elementary)

• Grades 9 through 11 (Some high school)

• Grade 12 or GED (High school graduate)

• College 1 year to 3 years (Some college or technical school)

• College 4 years or more (College graduate)

5. Are you currently…?

• Employed for wages

• Self-employed

• Out of work for 1 year or more

• Out of work for less than 1 year

• A homemaker

• A student

• Retired

• Unable to work

6. Are you…?

• Never married

• Married

• Member of an unmarried couple

• Widowed

• Divorced

• Separated

7. Which of the following best describes the location of your primary residence? Is it in a…?

• Large city

• Small city, suburban area, or large town

• Village or rural area

• A reservation

8. Have you ever participated in a group or program to improve your health or help you control an illness/sickness?

• Yes

• No

9. Is your annual household income from all sources…?

• Less than $10,000

• $10,000 to $14,999

• $15,000 to $19,999

• $20,000 to $24,999

• $25,000 to $34,999

• $35,000 to $49,999

• $50,000 to $74,999

• $75,000 to $99,999

• $100,000 to $124,999

• $125,000 to $149,999

• $150,000 or more