Rapid Message Testing with Consumer Panel - Testosterone Medication Guide

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FDA RAPID – MESSAGE #11
Testosterone Medication Guide

Introduction
The U.S. Food and Drug Administration, or FDA, hired Westat to help them get opinions about health information. Research Now is helping Westat and FDA find people who may be interested in being interviewed about health information. To make sure you are a good fit for the interview, please take about 3 minutes to answer the questions below.
1. What is your gender?
    a. Female	 INELIGIBLE
    b. Male
2. What is your age?
    a. Under 40	 INELIGIBLE
    b. 40 to 49	
    c. 50 to 59	
    d. 60 or older	 INELIGIBLE
3. Do any children 17 years old or younger live in your household?
YES	
NO	 GO TO Q5
Don’t Know	 INELIGIBLE

4. What age are the children living in your household? Mark all that apply.
    a. 4 years old or younger
    b. 5 to 7 years old
    c. 8 to 12 years old
    d. 13 to 17 years old
    e. 18 years old or older	 INELIGIBLE if not Yes to Q4a-d

5. What is the highest grade or level of education you have completed?
    a. Less than High School
    b. High School Diploma or GED
    c. Some Cllege, including Associate’s Degree	
    d. Bachelor’s Degree (for example: BA, BS)	
    e. Graduate or Professional Degree	 INELIGIBLE
6. Do you currently work for pay?
YES		
NO 	 GO TO Q8
7. What kind of work do you do?
OPEN-ENDED TEXT BOX		
8. Are you of Hispanic, Latino, or Spanish origin?
YES		
NO	
9. What is your race?  Please select one or more.
White			
Black or African-American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander	
10. What state do you live in? [DROP DOWN LIST OF US STATES, INCLUDING “OUTSIDE OF THE US”] [“OUTSIDE OF THE US”  INELIGIBLE]



Request for Contact Information 
C1. Thank you for answering the questions.  Based on your answers, you may be chosen for an interview.  If you are chosen for the interview and you finish it, you will get $50 E-Rewards Currency. At the start of the interview, the interviewer will ask if it’s okay to audio record it. This helps Westat to make sure they hear everything you say correctly. If you are chosen for an interview, you will get a package in the mail. Make sure to have the package with you during the interview. Is it okay with you for Research Now to share your contact information with Westat?

YES
NO		 INELIGIBLE
Thank and Terminate
Thank you for taking our survey. Unfortunately, based on your responses, you are not eligible for this study.  However, we appreciate you taking the time to answer our questions today. 

Contact Information
C2. In the space below, please give us the best information to contact you by phone, email, and regular mail. Please know that Research Now and Westat will not share your information with anyone else.
Contact Information

Name	______________________________________________________________________

Address 1 ___________________________________________________________________

Address 2 ___________________________________________________________________

City, State, ZIP _______________________________________________________________

Phone Number	_______________________________________________________________

Email Address________________________________________________________________

Available Times
C3. Someone from Westat will call or email in the next 1-2 days to schedule an interview with you. Please mark the times you can be reached by phone in the next 1-2 days.
9 a.m. to Noon
Noon to 2 p.m.
2 p.m. to 5 p.m.
5 p.m. to 7 p.m.
7 p.m. to 9 p.m.

Technology Preferences
C4. The Westat interviewer would like to be able to show you information on her computer screen during the interview. Westat will send directions for how to view the interviewer’s screen. Which app do you prefer for screen sharing? [SINGLE SELECT]
    a. Skype
    b. Google Hangouts
    c. WebEx
    d. I am not able to use any of these, please just call me

Closing
Thank you for your answers to these questions.  If you are chosen for an interview, someone from Westat will contact you within the next 1-2 days.