Rapid Message Testing With Consumer Panel - Asthma Fact Sheet

OMB Control No. 0910-0695

Expiration date: 2/28/2021

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0910-0695 and the expiration date is 2/28/2021. The time required to complete this information collection is estimated to average 3 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information.

FDA RAPID – MESSAGE #12

Asthma Fact Sheet

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?

1. Female

2. Male

2. What is your age?

1. Under 18  INELIGIBLE

2. 18 to 29

3. 30 to 49

4. 50 to 64

5. 65 or older  INELIGIBLE

3. Has a doctor, nurse, or other health professional ever told you that you have asthma?¹

1. Yes

2. No  GO TO Q5

3. Don’t know  GO TO Q5

4. Do you still have asthma?

1. Yes

2. No

3. Don’t know

5. Do any children 17 years old or younger live in your household?

YES

NO  GO TO Q9, INELIGIBLE if Q4 not Yes

Don’t Know  GO TO Q9, INELIGIBLE if Q4 not Yes

6. What age are the children living in your household? Mark all that apply.

1. 4 years old or younger

2. 5 to 7 years old

3. 8 to 12 years old

4. 13 to 17 years old

7. Has a doctor, nurse, or other health professional ever told you that a child living with you has asthma?

1. Yes

2. No  INELIGIBLE if Q4 not Yes

3. Don’t know  INELIGIBLE if Q4 not Yes

8. Does this child still have asthma?

1. Yes

2. No  INELIGIBLE if Q4 not Yes

3. Don’t know  INELIGIBLE if Q4 not Yes

9. What is the highest grade or level of education you have completed?

1. Less than High School

2. High School Diploma or GED

3. Some College, including Associate’s Degree

4. Bachelor’s Degree (for example: BA, BS)

5. Graduate or Professional Degree  INELIGIBLE

10. Do you currently work for pay?

YES

NO  GO TO Q12

11. What kind of work do you do?

OPEN-ENDED TEXT BOX

12. Are you of Hispanic, Latino, or Spanish origin?

YES

NO

13. 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

14. What language do you speak most often at home?

English  ELIGIBLE for English interview

Spanish GO TO Q15

Other  INELIGIBLE

15. [Ask if Q14=Spanish] How well do you speak Spanish?

Very well

Well

Not well  INELIGIBLE

Not at all  INELIGIBLE

16. [Ask if Q14=Spanish] How well do you read Spanish?

Very well  ELIGIBLE for Spanish interview

Well  ELIGIBLE for Spanish interview

Not well  INELIGIBLE

Not at all  INELIGIBLE

17. 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 $35 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]

1. Skype

2. Google Hangouts

3. WebEx

4. 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.

1 Asthma questions based on CDC’s 2018 Behavioral Risk Factor Surveillance System survey