Attachment 13c: Screener for Field Test
Form Approved OMB No. 0920-1061
Exp. Date 3/31/2018
Public reporting burden of this collection of information is estimated to average 1 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1061).
Interviewer’s Screener Script
HELLO, I am calling for the [state health department]. My name is [name]. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices [including any changes in your behavior as a result of the resent Zika outbreak].
LL 1. Is this (phone number) ?
If "No”
Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time. STOP
LL 2. Is this a private residence?
READ ONLY IF NECESSARY: “By private residence, we mean someplace like a house or apartment.”
Yes [Go to state of residence]
No [Go to college housing]
No, business phone only
If “No, business phone only”.
Thank you very much but we are only interviewing persons on residential phones lines at this time.
STOP
College Housing
LL3. Do you live in college housing?
READ ONLY IF NECESSARY: “By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.”
Yes
No
If "No”,
Thank you very much, but we are only interviewing persons who live in a private residence or college housing at this time. STOP
CP 1. Is this a cellular telephone?
INTERVIEWER NOTE: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services).
READ ONLY IF NECESSARY: “By cellular (or cell) telephone we mean a telephone that is mobile and usable outside of your neighborhood.”
If “Yes”
Thank you very much, but we are only interviewing by land line telephones and for private residences or college housing. STOP
CP 2. Is this a safe time to talk with you? (or are you driving?)
1 Yes, respondent is male [Go to CP 2]
2 No, [Make appointment or place number in call back schedule]
CP 3. Are you 18 years of age or older?
1 Yes, respondent is male [Go to Section 1]
2 Yes, respondent is female [Go to Section 1]
3 No
If "No”,
Thank you very much, but we are only interviewing persons aged 18 or older at this time. STOP
CP 4. Do you live in a private residence?
READ ONLY IF NECESSARY: “By private residence, we mean someplace like a house or apartment.”
Yes [Go to state of residence]
No [Go to college housing]
No, business phone only
If “No, business phone only”.
Thank you very much but we are only interviewing persons on residential phones lines at this time.
STOP
College Housing
CP 5. Do you live in college housing?
READ ONLY IF NECESSARY: “By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university.”
Yes
No
If "No”,
Thank you very much, but we are only interviewing persons who live in a private residence or college housing at this time. STOP
State of Residence
CP 6. Do you reside in ____(state)____?
Yes [Go to Section 1]
No [Go to CP7]
CP 7. In what state do you reside?
State______
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Pierannunzi, Carol (CDC/ONDIEH/NCCDPHP) |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |