Form Approved

OMB No. 0923-17IY

Exp. Date xx/xx/201x

Attachment 5d. Eligibility Screening Survey for Burmese Immigrants and their Descendants

Date Administered (MM/DD/YYYY): __ /__ /____

Instructions for survey administrator: This instrument will screen volunteers upon arrival to see if they are eligible to participate in the study. Please fill out this [form/ instrument] for each person in the presence of the interpreter. If the respondent meets the criteria, please ask him/her to wait for the next available appointment time. To be eligible, participants must:

• be at least 18 years of age;

• have lived in Milwaukee for the last 12 months;

• not be pregnant, if female;

• have eaten at least one fish meal from the water bodies of concern; and

• be the only/first member of the household participating in the study.

Each person should have a referral invitation that was given to them by someone from the community.

Interviewer script: The person who asked you to join this study should have given you an invitation. Do you have that with you?

If yes, record the SPID here: _____________

If no, ask for the name of the person who gave him/her the invitation: ___________________

Interviewer script: I would like to ask you some questions to make sure that you are eligible to participate in this study.

1. Are you at least 18 years old? YES NO
   If YES, continue to #2. If NO, thank for their time and tell them that they are not eligible at this time.
   
   

2. Have you lived in Milwaukee, Wisconsin for the last 12 months? YES NO
   If YES, continue to #3. If NO, thank for their time and tell them that they are not eligible at this time.
   
   

   ATSDR estimates the average public reporting burden for this collection of information as 5 minutes 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, Georgia 30333; ATTN: PRA (0923-17IY).

3. If male, skip to Question 4. If Female ask: Are you currently pregnant? YES NO
   If NO, continue to #4. If YES, thank for their time and tell them that they are not eligible at this time.
   
   
   

5. During the past 12 months, did you eat at least one fish meal caught in any of the water bodies pictured below? Show map of Milwaukee AOC water bodies. YES NO
   If YES, continue to #4. If NO, thank for their time and tell them that they are not eligible at this time.
   
   

6. As far as you know, has anyone else in your household participated in this study before you? YES NO
   If NO, continue to appointment instructions. If YES, thank for their time and tell them that they are not eligible at this time and ask if we can contact them if a spot opens up (e.g., if we have trouble meeting recruitment goals).

Instructions for the survey administrator:

• If participant meets all eligibility requirements, give instructions to wait for the next available interviewer for their study appointment.

• If the participant does not meet the eligibility requirements, thank them for their time and provide the following: education materials, bus pass or parking reimbursement.