Telephone Introductory Script and Informed Consent - English

Attachment 5a

Telephone Follow-up Survey Introductory Script, Consent and Voicemail message - English

Telephone Introduction (English)

Introduction

Hello, my name is <interviewer name> and I’m calling from the Puerto Rico Department of Health about a research project we are doing to learn more about the health of women in Puerto Rico.

1. Is this <mother’s name>?

YES  PROCEDE TO QUESTION 2

NO

IF THE PERSON ASKS WHY YOU WANT TO SPEAK WITH THE RESPONDENT,

SAY: “I am from the Puerto Rico Department of Health and we would like her help in a survey we are doing about women’s health in Puerto Rico.”

IF THE PARTICIPANT IS NOT AVAILABLE, THEN:

1. INSERT CORRECT CODE IN INTERVIEW FORM

 MOTHER NOT AVAILABLE, FOLLOW UP CALL WASN’T ARRANGED

 MOTHER NOT AVAILABLE, FOLLOW UP CALL WAS ARRANGED

 MOTHER NOT AVAILABLE, MESSAGE LEFT FOR MOM TO CALL BACK

 INTERVIEWER WAS INDICATED THAT NUMBER IS INCORRECT NUMBER

2. INDICATE IF A REASON WAS GIVEN FOR MOM NOT BEING AVAILABLE

3. APPRECIATE ALL THE HELP AND INFORMATION. END CALL.

IF PARTICIPANT CAN’T BE REACHED AT THAT NUMBER/LOCATION, THEN:

1. ASK: “How can we reach her?”

2. INSERT CORRECT CODE IN INTERVIEW FORM

 ADDITIONAL CONTACT NUMBER WAS PROVIDED

[Telephone Number:_____________________]

 NO ADDITIONAL CONTACT INFORMATION WAS PROVIDED

3. APPRECIATE ALL THE HELP AND INFORMATION. END CALL.

2. We would like to invite you to participate in a short telephone survey, but first, I’d like to make sure that I am talking with the right person.

You are <mother’s name> and you were born in <mother’s year of birth>. Is that correct?

YES  CONTINUE TO PART II

NO  PROCEDE TO NEXT QUESTION

REMEMBER: DO NOT GIVE OUT ANY CONFIDENTIAL INFORMATION FROM
PRAMS-ZPER UNTIL YOU KNOW YOU HAVE THE CORRECT PERSON.

3. What information is not correct?

 Name  1st Last Name  2nd Last Name  Year of Birth

DESCRIBE SITUATION (MOM USES MAIDEN NAME, ETC.):

IF THE MOM GIVES A YEAR OF BIRTH VERY DIFFERENT (+ 2 years) FROM WHAT YOU READ, ASK: Have you recently lived at <street address>?

YES

NO

IF YOU ARE SATISFIED YOU HAVE THE CORRECT PERSON, CONTINUE WITH PART II AND SAY: ““I have a brief introduction to read to you before we begin”

IF YOU DO NOT HAVE THE CORRECT PERSON, SAY: “I’m sorry. It seems we reached you by mistake. Thank you for your time”. END CALL.

Informed Consent Document Telephone Follow-up survey (English – Baby Alive)

ZPER is short for the Zika Postpartum Emergency Response. The ZPER Telephone Follow-up study is sponsored by the Centers for Disease Control and Prevention and Puerto Rico Department of Health Division of Maternal, Child and Adolescent Health. We would like to invite you to answer some questions about your experiences since your most recent pregnancy. Your participation can help us learn more about ways to protect women and infants from Zika virus infection and build programs to benefit mothers and babies in Puerto Rico.

We are asking over approximately? 1,400 other women in Puerto Rico to answer these same questions. Your name was picked by a computer from a list of women who recently participated in the Puerto Rico Department of Health ZPER hospital survey in the fall of 2016.

Your answers are very important, whether you and your baby have been healthy or sick. We ask that you do the interview because your answers are important, and could help other mothers and babies in the future.

Most questions are about your health and life since the birth of your most recent baby. It takes about 15 - 20 minutes to answer all the questions. Some questions may be sensitive, such as questions about contraceptive use.

You are free to do the survey or not. If you don’t want to participate at all, or if you don’t want to answer a particular question, that’s okay. There is no penalty or loss of benefits for not participating or answering all questions.

Your answers will be grouped with those from other women. The answers you provide are anonymous, your name will not be on any reports from PRAMS-ZPER. Your survey may be combined with additional information the health department has from other sources.

If you choose to do the survey, your answers will be kept private to the extent allowed by law and will be used only for research. What we learn from the Zika Postpartum Emergency Response Telephone Follow-up Survey will be used to plan programs to help mothers and babies in Puerto Rico.

If you have questions about the ZPER Telephone Follow-up survey, please call Beatriz Salvesen, the Puerto Rico ZPER Project Coordinator, at 787-765-2929, extension 4672.

If you have any questions about your rights in the project, please call the Human Research Subjects Protection Office at 787-758-2525, extension 2510 and 2515.

4. Shall we begin?

YES  CONTINUE TO PART III

NO  SAY: “If this is not a good time to talk, I can call back later.”

TRY TO SCHEDULE A CONVENIENT TIME TO INTERVIEW MOTHER.

1. THANK RESPONDENT.

2. ENTER APPROPRIATE CODE ON TELEPHONE INTERVIEW FORM:

 RECORD IF NO TIME SCHEDULED FOR CALL BACK.

 RECORD IF TIME SCHEDULED FOR CALL BACK.

 RECORD IF MOM WILL CALL PRAMS-ZPER OFFICE.

IF MOTHER DOES NOT WANT TO DO INTERVIEW LATER, THEN:

1. THANK THE RESPONDENT

2. ENTER THE APPROPRIATE CODE ON TELEPHONE INTERVIEW FORM:

 RECORD IF HARD REFUSAL.

 RECORD IF JUDGED A SOFT REFUSAL TO BE FOLLOWED-UP.

3. NOTE THE REASON FOR REFUSAL

DO NOT READ ALOUD THE FOLLOWING

THIS IS TO CERTIFY THAT I HAVE READ THE ENTIRE INTRODUCTION
ABOVE TO THE RESPONDENT.

___________________________________________ _________________

(SIGNATURE OF INTERVIEWER) (DATE)

Start Survey:

Please give me your answers as I read the questions to you.

***MOTHER OF TWINS OR MULTIPLE BIRTHS ONLY***

Some of the questions are about mothers and some are about babies.
For the questions about babies, please answer only for <baby’s name>.

GO TO PAGE 1 AND BEGIN THE QUESTIONNAIRE.

Informed Consent Document Telephone Follow-up survey (English – Baby Deceased)

ZPER is short for the Zika Postpartum Emergency Response. The ZPER Telephone Follow-up study is sponsored by the Centers for Disease Control and Prevention and Puerto Rico Department of Health Division of Maternal, Child and Adolescent Health. We would like to invite you to answer some questions about your experiences since your most recent pregnancy. Your participation can help us learn more about ways to protect women and infants from Zika virus infection and build programs to benefit women and babies in Puerto Rico.

We are asking over 1,400 other women in Puerto Rico to answer these same questions. Your name was picked by a computer from a list of women who recently participated in the Puerto Rico Department of Health ZPER hospital survey in the fall of 2016.

Your answers are very important, whether you and your baby have been healthy or sick.

We understand that you baby passed away. We are truly sorry about your loss and offer our sympathy and condolences to you and your family. We also ask that you complete the interview because your answers are important, and could help other women that are going through similar experiences.

Most questions are about your health and life since your most recent delivery. It takes about 15 - 20 minutes to answer all the questions. Some questions may be sensitive, such as questions about contraceptive use.

You are free to do the survey or not. If you don’t want to participate at all, or if you don’t want to answer a particular question, that’s okay. There is no penalty or loss of benefits for not participating or answering all questions.

Your answers will be grouped with those from other women. The answers you provide are anonymous, your name will not be on any reports from PRAMS-ZPER. Your survey may be combined with additional information the health department has from other sources.

If you choose to do the survey, your answers will be kept private to the extent allowed by law and will be used only for research. What we learn from the Zika Postpartum Emergency Response Telephone Follow-up Survey will be used to plan programs to help women and babies in Puerto Rico.

If you have questions about the ZPER Telephone Follow-up survey, please call Beatriz Salvesen, the Puerto Rico ZPER Project Coordinator, at 787-765-2929, extension 4672.

If you have any questions about your rights in the project, please call the Human Research Subjects Protection Office at 787-758-2525, extension 2510 and 2515.

5. Shall we begin?

YES  CONTINUE TO PART III

NO  SAY: “If this is not a good time to talk, I can call back later.”

TRY TO SCHEDULE A CONVENIENT TIME TO INTERVIEW MOTHER.

1. THANK RESPONDENT.

2. ENTER APPROPRIATE CODE ON TELEPHONE INTERVIEW FORM:

 RECORD IF NO TIME SCHEDULED FOR CALL BACK.

 RECORD IF TIME SCHEDULED FOR CALL BACK.

 RECORD IF MOM WILL CALL PRAMS-ZPER OFFICE.

IF MOTHER DOES NOT WANT TO DO INTERVIEW LATER, THEN:

1. THANK THE RESPONDENT

2. ENTER THE APPROPRIATE CODE ON TELEPHONE INTERVIEW FORM:

 RECORD IF HARD REFUSAL.

 RECORD IF JUDGED A SOFT REFUSAL TO BE FOLLOWED-UP.

3. NOTE THE REASON FOR REFUSAL

DO NOT READ ALOUD THE FOLLOWING

THIS IS TO CERTIFY THAT I HAVE READ THE ENTIRE INTRODUCTION
ABOVE TO THE RESPONDENT.

___________________________________________ _________________

(SIGNATURE OF INTERVIEWER) (DATE)

Start Survey:

Please give me your answers as I read the questions to you.

***MOTHER OF TWINS OR MULTIPLE BIRTHS ONLY***

Some of the questions are about mothers and some are about babies.
For the questions about babies, please answer only for <baby’s name>.

GO TO PAGE 1 AND BEGIN THE QUESTIONNAIRE.

Voicemail Message (English)

"I'm calling for <mom’s name>. This is <interviewer name> from the Puerto Rico Department of Health. I’m contacting you about a health survey.

If you have the opportunity, please call me back between 8:30 am – 4:00 pm at 787-765-2929, extension 4672. If I don't hear from you, I'll call you again within the next few days. Thank you. Good-bye.”

OR

“I’m calling for < mom’s name >. This is < interviewer name > from the Puerto Rico Department of Health. I’m contacting you about a health survey.

If this is not the correct number for < mom’s name > please call me back between at 787-765-2929, extension 4672 so that I can remove you from our calling list.

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