Jurisdictional MCH Pretest Appendix B- Script for Phone Mode 7.9.18

Appendix B: SCRIPT FOR PHONE MODE OMB control #: 0915-0379

Expiration Date: 06/30/2020

Hello, my name is _________. I am calling on behalf of the Health Resources and Services Administration, Maternal and Child Health Bureau at the U.S. Department of Health and Human Services.

I am part of a research study that is being done to learn more about mother’s and children’s health in [Guam/Puerto Rico/ U.S. Virgin Islands]. Your participation in this study would involve answering a series of questions about your and your children’s health.

[If respondent is Female got to 1, if respondent is Male or you are unsure, go to question 4]

1. Your telephone number has been chosen randomly. Can I ask you a few questions to see if you are eligible to participate in this study?

1 Yes [go to 2]
2 No [Thank individual for their time and end call]

99. Refused to Answer [Thank individual for their time and end call]

2. Are you 18 years of age or older?

1 Yes [go to 3]
2 No [go to 4]

99. Refused to Answer [Thank individual for their time and end call]

3. Are you the mother of a child 0 to 17 years old living in your household?

1 Yes [go to screener]
2 No [go to 4]

99 Refused to Answer

4. Is there a woman in your household 18 years of age or older who is the mother of a child 0 to 17 years old that I could to talk to?

1 Yes [go to beginning]

2 Yes but she is unavailable [Go to 5]
2 No [go to Thank individual for their time and end call]

99 Refused to Answer

5. Is there a better time to call back and speak with her?

1 Yes [Write down time]

2 No [Thank individual for their time and end call]

3 Refused to Answer [Thank individual for their time and end call]

[INFORMED CONSENT SCRIPT READ AFTER DETERMINING ELIGIBLE CHILD(REN) IN THE HOUSEHOLD AND PRIOR TO LAUNCHING CORE QUESTIONNAIRE]

We are testing survey questions to learn more about mother’s and children’s health. We are doing this test in American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Palau, Puerto Rico, and U.S. Virgin Islands. These areas are part of the Title V Maternal Child Health Block (or MCH) Grant program. Local MCH programs will use these questions to understand the health of mothers and children. This will help them develop services for families.

You will be asked to answer survey questions that are read out loud to you. The questions are about your and your child’s health. For example, we will ask about your child as a baby, caring for your child, and your child’s learning. We will also ask about illnesses you or your child may have had, doctors you and your child see, household information, and other kinds of questions.

You don’t have to be in this study. You can agree to be in the study now and change your mind later. You do not have to answer any questions you do not want to answer. Your decision to not answer questions or to stop answering questions will not change anything.

There are no risks in answering these survey questions beyond the risks that are in everyday life. Some of the questions about health, drug or alcohol use, or feelings are personal and might make you uncomfortable.

There is no direct help to you for answering the survey questions, your answers may help provide better information about the health of mothers and children and the work of the Title V MCH Block grant program.

It will take about 40 minutes to answer the questions.

The only people allowed to see your answers will be the people who work on the study and people who make sure we run the study the right way. Your name will not be on the survey with your answers. We will use a number code to track your answers, not your name.

The survey does not ask about child abuse or neglect. If we learn about child abuse or neglect that is happening now or is ongoing, we will have to report this to the proper authorities.

Your answers will be kept in secure NORC servers at all times.

If you stop answering questions before the end of the survey, you can ask us to erase your responses.

We have asked the U.S. Department of Health and Human Services (DHHS) to give this study a legal document, called a Certificate of Confidentiality. This means that the study cannot be made to give out your answers in any court. We will only share your answers if you request it.

Studies like this one can be looked at by the United States Government. If that happens, we cannot use the Certificate of Confidentiality to keep your answers from staff doing the review.

In order to review my work, this call will be recorded and my supervisor may listen as I ask the questions. Only approved staff members from NORC who are working on this project will have access to recordings. These recordings will be kept in secure NORC servers at all times. This recording will be erased once the project has ended.

[IF RESPONDENT OBJECTS TO RECORDING, STOP THE RECORDING AND EXPLAIN TO THE PARTICIPANT THAT THE INTERVIEW CAN CONTINUE WITHOUT RECORDING.]

Do you have any questions?

[ANSWER ANY RESPONDENT QUESTIONS OR CONCERNS.]

Do you agree to participate in this study as I have described it?

[CHECK OFF THIS BOX IF PARTICIPANT EXPRESSED VERBAL CONSENT]

□ YES □ NO

[IF RESPONDENT DOES NOT CONSENT, THANK HER FOR HER TIME AND END INTERVIEW, IF RESPONDENT DOES CONSENT, LAUNCH CORE QUESIONNAIRE]

[ADDITIONAL INFORMATION PROVIDED AT END OF SURVEY]

On behalf of the U.S. Department of Health and Human Services, we would like to thank you for the time and effort you have spent sharing information about this child, you, and your family.

Your answers are important to us and will help researchers, policymakers, and family advocates to better understand the health and health care needs of children in our diverse population.

Please contact Clare Davidson at [toll free number pending] or [email protected] with questions, complaints or concerns about this study. If you have any questions or concerns about your rights as a research participant, please contact the NORC Institutional Review Board Manager by toll-free phone number at (866) 309-0542. Thank you again.