Jurisdictional MCH Pretest Appendix C- Script for In Person Mode 7.9.18

Appendix C: SCRIPT FOR IN-PERSON MODE OMB control #: 0915-0379

Expiration Date: 06/30/2020

Hello, my name is _________. I am talking with people 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 better understand mother’s and children’s health in [American Samoa/Federated States of Micronesia/Marshall Islands/Northern Mariana Islands/Palau]. Your participation in this study would involve answering a series of questions about your and your children’s health.

1. 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 [Thank individual for their time and end call]

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 [Thank individual for their time and end call]

99 Refused to Answer

[WRITTEN INFORMED CONSENT OBTAINED AFTER DETERMINING ELIGIBLE CHILD(REN) IN THE HOUSEHOLD AND PRIOR TO LAUNCHING CORE QUESTIONNAIRE- SEE SEPARATE FORM]

[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.

[FOR AMERICAN SAMOA/FEDERATED STATES OF MICRONESIA/NORTHERN MARIANA ISLANDS]

[FOR ALL IN-PERSON RESPONDENTS]

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.