Survey and Consent - ZRHER

Attachment 5

Zika Reproductive Health and Emergency Response

Call-Back Survey (ZRHER), 2017

Survey and Consent

Public reporting burden of this collection of information is estimated to average 10 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-xxxx).

Introductory Script: HELLO, I am calling for the ___(health department)___. My name is (name) . We are gathering information about the health of ___(state)___residents, specifically their health practices related to the Zika virus and other public health emergencies. During a recent phone interview (sample person first name or initials) indicated she would be willing to participate in this survey. This project is conducted by the [STATE] Health Department with assistance from the Centers for Disease Control and Prevention.

S1. Is this (phone number)?

Yes

No-->[Confirm phone number] AND SAY: “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.” END INTERVIEW

S2. Are you (sample person first name or initials)?

Yes

No Ask if person is available. If not, schedule a time to call in the future.

Participation in this survey is voluntary. You may skip or refuse to answer any question. We will not ask you for any personal information, such as your name or address and your responses will be confidential. The survey takes about 10 minutes to complete.

S3. Is this a good time to talk with you?

Yes

Nosay “Thank you very much. We will call you back at a more convenient time.” STOP

(SET APPOINTMENT IF POSSIBLE)

Section 1: Zika-Related Knowledge and Healthcare Provider Communication

First, I will ask a few questions to see what you know and have learned about Zika and travel recommendations from your doctor or other healthcare workers.

1. At any time, has a doctor, nurse, or other healthcare worker talked to you about Zika?

DO NOT READ:

1 Yes

2 No [Go to Q1.3]

7 Don’t Know/Not sure [Go to Q1.3]

9. Refused [Go to Q1.3]

2. Did you ask about Zika before that discussion?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9. Refused

3. The last time you spoke to a doctor, nurse or other healthcare worker, did that person ask you whether you had recently traveled outside of the United States?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9. Refused

4. The last time you spoke to a doctor, nurse or other healthcare worker, did that person ask you whether you had plans to travel outside of the United States?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9. Refused

5. Do you think it is safe for a pregnant woman to travel to areas where there is Zika virus?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9. Refused to answer

6. Do you think a woman should wait to try to get pregnant after she has traveled to an area with Zika virus?

DO NOT READ:

1 Yes

2 No [GO TO Q1.8]

7 Don’t Know/Not sure [GO TO Q1.8]

9. Refused to answer [GO TO Q1.8]

7. How long should a woman wait to try to get pregnant after she returns from an area with Zika virus? Would you say she should wait…?

READ:

1 2 WEEKS (to less than 4 weeks)

2 4 WEEKS (to less than 6 weeks)

3 6 WEEKS (to less than 8 weeks)

4 8 WEEKS (to less than 6 months)

5 6 MONTHS (to less than 1 year)

6 1 YEAR (or more)

DO NOT READ:

7 Don’t Know/Not sure

9. Refused to answer

8. Do you think a woman should wait to try to get pregnant after her male partner has traveled to an area with Zika virus?

DO NOT READ:

1 Yes

2 No [GO TO Q2.1]

7 Don’t Know/Not sure [GO TO Q2.1]

9. Refused to answer [ GO TO Q2.1]

9. How long should a woman wait to try to get pregnant after her male partner returns? Would you say she should wait…?

READ:

1 2 WEEKS (to less than 4 weeks)

2 4 WEEKS (to less than 6 weeks)

3 6 WEEKS (to less than 8 weeks)

4 8 WEEKS (to less than 6 months)

5 6 MONTHS (to less than 1 year)

6 1 YEAR (or more)

DO NOT READ:

7 Don’t Know/Not sure

9 Refused to answer

Section 2: Having Children and Use of Birth Control

The next set of questions asks you about your thoughts and experiences with birth control and plans for having children. Please remember that all of your answers will be kept confidential.

1. Did you or your partner do anything the last time you had vaginal sex in the past year to keep you from getting pregnant?

1 Yes [GO TO Q2.4]

2 No

3 No partner/not sexually active [GO Q2.11]

4 Same sex partner [GO TO Q2.11]

DO NOT READ:

7 Don’t know/Not sure [GO TO Q2.9]

9 Refused [GO TO Q2.9]

Some reasons for not doing anything to keep from getting pregnant the last time you had vaginal sex might include wanting a pregnancy, not being able to pay for birth control, or not thinking you can get pregnant.

2. What was your main reason for not doing anything the last time you had vaginal sex in the past year to keep you from getting pregnant?

INTERVIEWER NOTE: IF RESPONDENT REPORTS “OTHER REASON,” ASK RESPONDENT TO “PLEASE SPECIFY” AND ENSURE THAT THEIR RESPONSE DOES NOT FIT INTO ANOTHER CATEGORY. IF RESPONSE DOES FIT INTO ANOTHER CATEGORY, PLEASE MARK APPROPRIATELY.

Read only if respondent is unable to provide a response:

1. You didn’t think you were going to have sex/no regular partner

02 You just didn’t think about it

03 Don’t care if you get pregnant

04 You want a pregnancy

05 You or your partner don’t want to use birth control

06 You or your partner don’t like birth control/side effects

07 You couldn’t pay for birth control

08 You had a problem getting birth control when you needed it

09 Religious reasons

10 Lapse in use of a method

11 Don’t think you or your partner can get pregnant (infertile or too old)

12 You had tubes tied (sterilization)

13 You had an implant, or IUD in place

14 You had a hysterectomy

15 Your partner had a vasectomy (sterilization)

16 You are currently breast-feeding

17 You just had a baby/postpartum

18 You are pregnant now [GO TO Q2.9]

19 Same sex partner only

20 Other reasons

DO NOT READ:

77 Don’t know/Not sure

99 Refused

3. If you did not have to worry about cost and could use any type of birth control method, would you want to use a method?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

[CATI NOTE: GO TO Q 2.9]

4. What did you or your partner do the last time you had vaginal sex in the past year to keep you from getting pregnant?

[INTERVIEWER NOTE: PRONUNCIATION – “Essure”=“ee-shure”; “Adiana”=“ay-dee-ah-na” “Nexplanon”=“nex-plan-ahn”; “Mirena”=”mee-ray-na”; “ParaGard”=”pare-ah-gard”; “Depo-Provera”=”dep-oh pro-ver­-ah”; “Ortho Evra”=”or-tho ehv-ra”; “NuvaRing”=”noo-va-ring”]

[INTERVIEWER NOTE: IF RESPONDENT REPORTS USING MORE THAN ONE METHOD, PLEASE CODE THE METHOD THAT OCCURS FIRST ON THE LIST.

INTERVIEWER NOTE: IF RESPONDENT REPORTS USING “CONDOMS,” PROBE TO DETERMINE IF “FEMALE CONDOMS” OR MALE CONDOMS”]

[INTERVIEWER NOTE: IF RESPONDENT REPORTS USING AN “IUD” PROBE TO DETERMINE IF “LEVONORGESTREL IUD” OR “COPPER-BEARING IUD”]

INTERVIEWER NOTE: IF RESPONDENT REPORTS “OTHER METHOD,” ASK RESPONDENT TO “PLEASE SPECIFY” AND ENSURE THAT THEIR RESPONSE DOES NOT FIT INTO ANOTHER CATEGORY. IF RESPONSE DOES FIT INTO ANOTHER CATEGORY, PLEASE MARK APPROPRIATELY.

Read only if respondent is unable to provide a response:

01 Female sterilization (ex. Tubal ligation, Essure, Adiana)

02 Male sterilization (vasectomy)

03 Contraceptive implant (ex. Nexplanon)

04 IUD, Levonorgestrel (LNG), hormonal (ex. Mirena, Skyla, Liletta, Kylena)

05 IUD, Copper-bearing (ex. ParaGard)

06 IUD, type unknown

07 Shots (ex. Depo-Provera or DMPA)

08 Birth control pills, any kind

09 Contraceptive patch (ex. Ortho Evra, Xulane)

10 Contraceptive ring (ex. NuvaRing)

11 Male condoms

12 Diaphragm, cervical cap, sponge

13 Female condoms

14 Not having sex at certain times (rhythm or natural family planning)

15 Withdrawal (or pulling out)

16 Foam, jelly, film, or cream (spermicide)

17 Emergency contraceptive pills (ex. Ella, Plan B or morning after pill)

18 Other method

DO NOT READ:

77 Don’t know/Not sure

99 Refused

[CATI NOTE: COMPLETE BLANK WITH RESPONSE TO Q 2.4, USING HIGHEST METHOD ON LIST THAT WAS CODED]

5. As best as you can remember, what month and year did you start using ______________________ ?

Month ___ ___ Year  ___ ___ ___ ___

77/7777 Don’t Know/Not sure

99/9999 Refused to answer

6. What was your most important reason for starting that particular method?

[INTERVIEWER NOTE: REFERS TO RESPONSE CODED FOR Q2.4]

DO NOT READ:

1 Recently got health insurance

2 Lost health insurance/couldn’t pay for method I was using

3 Didn’t like the method I was using

4 In a new relationship

5 Recently became sexually active

6 Concerned about Zika

7 Other reasons

8 Recently had a baby

77 Don’t Know/Not sure

99 Refused to answer

7. If you did not have to worry about cost and could use any birth control method, would you want to use a different method?

DO NOT READ:

1 Yes

2 No

7 Don’t Know/Not sure

9 Refused to answer

[CATI NOTE: IF Q 2.4 = 11 or 13 or Q2.2 > 13 GO TO Q 2.11]

8. In addition to the birth control method we just discussed, the last time you had vaginal sex in the past year, did you and your partner use a condom?

1 Yes [GO TO Q2.10]

2 No

7 Don’t Know/Not sure

9 Refused to answer

9. Have you used a condom with a male partner at any time in the past year?

1 Yes

2 No [IF Q2.1=18 GO TO Q2.14; ELSE GO TO Q2.11]

7 Don’t know/Not sure [IF Q2.1=18 GO TO Q2.14; ELSE GO TO Q2.11]

9 Refused [IF Q2.1=18 GO TO Q2.14; ELSE GO TO Q2.11]

10. Thinking back over the past year, would you say you used a condom when you had vaginal sex every time, most of the time, some of the time, or none of the time?

1 Every time,

2 Most of the time,

3 Some of the time, or

4 None of the time?

DO NOT READ:

7 Don’t Know/Not sure

9 Refused to answer

[CATI NOTE: IF Q2.1=18 GO TO Q2.14]

11. Are you currently pregnant?

DO NOT READ:

1 Yes [GO TO Q2.14]

2 No

7 Don’t Know/Not sure

9. Refused to answer

12. Have you ever been pregnant, including pregnancies that ended in miscarriage or abortion?

DO NOT READ:

1 Yes

2 No [GO TO Q 2.15]

7 Don’t Know/Not sure

9 Refused to answer

12. In what month and year did your most recent pregnancy end?

MONTH: __ __ YEAR: __ __ __ __

77/7777 Don’t Know/Not sure

99/9999 Refused to answer

12. Thinking back to just before you got pregnant [“with your most recent pregnancy”, if not currently pregnant], how did you feel about becoming pregnant? Would you say…

1 Wanted to be pregnant later

2 Wanted to be pregnant sooner

3 Wanted to be pregnant at that time

4 Didn’t want to be pregnant then or at any time in the future, or

5 Were not sure about what you wanted.

DO NOT READ:

7 Don’t know/Not sure

9 Refused

12. How do you feel about having a [“another” for pregnant women] child now or sometime in the future? Would you say?

READ:

1 You don’t want to have one/another

2 You want to have one, less than 1 year from now

3 You want to have one, between 1 to 2 years from now

4 You want to have one, between 2 and 5 years from now

5 You want to have one, at least 5 years from now

6 You want to have one, but not sure when

7 Not sure if want to have any/another

DO NOT READ:

9 Refused to answer

Section 3: Other Healthcare Questions

The next set of questions asks you about other aspects of your health. Please remember that all of your answers will be kept confidential.

3.1 Has a doctor, nurse, or other health care worker ever talked with you about ways to prepare for a healthy pregnancy and baby?

1 Yes

2 No

DO NOT READ:

7 Don‘t know / Not sure

9. Refused

3.2 In the past year, have you seen a health care provider about your own health?

1 Yes

2 No

DO NOT READ:

7. Don‘t know / Not sure

3.3 In the past year, have you seen a doctor who specializes in women’s health, such as an Obstetrician Gynecologist?

1 Yes

2 No

DO NOT READ:

7 Don‘t know / Not sure

9 Refused

3.4 Have you received a tetanus shot in the past 10 years?

[INTERVIEWER NOTE: IF YES, ASK: WAS THIS TDAP, THE TETANUS SHOT THAT ALSO HAS PERTUSSIS OR WHOOPING COUGH VACCINE?]

1 Yes, received TDAP

2 Yes, received tetanus shot, but not TDAP

3 Yes, received tetanus shot but not sure what type

4 No, did not receive any tetanus since 2005

DO NOT READ:

7 Don’t know/Not sure

9. Refused

3.5 Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, government plans such as Medicare, or Indian Health Service?

1 Yes

2 No [Go to Q 4.1]

7 Don’t know / Not sure [Go to Q 4.1]

9 Refused [Go to Q 4.1]

3.6 Read: What is the primary source of your health care coverage? Is it . . .READ

1. A plan purchased through an employer or union (including plans perchased through another person’s employer)

2. A plan that you or another family member buys on your own

3. Medicare

4. Medicaid or other state program

5. TRICARE (formerly CHAMPUS), VA, or Military

6. Alaska Native, Indian Health Service, Tribal Health Services

7. Some other source

8. None (no coverage)

DO NOT READ

77 Don’t know / Not sure

99 Refused

INTERVIEWER NOTE: If the respondent indicates that they purchased health insurance through the Health Insurance Marketplace (name of state Marketplace), ask if it was a private health insurance plan purchased on their own or by a family member (private) or if they received Medicaid (state plan)?  If purchased on their own (or by a family member), select 02, if Medicaid select 04

Section 4: Emergency Preparedness

Now I will ask you some questions about how prepared you and any other members of your household are for a major disaster or emergency. By major disaster or emergency we mean any event that leaves you isolated in your home or displaces you from your home for at least 3 days.

1. How many children under the age of 18 live in your home?

[CATI NOTE: IF Q4.1= 0 GO TO Q4.3]

2. Are you the primary caregiver for any of the children in your home?

1 Yes

2 No

DO NOT READ:

7 Don’t know / Not sure

9 Refused

3. How well prepared do you feel your household is to handle a large-scale disaster or emergency? Would you say your household is…

1 Well prepared

2 Somewhat prepared

3 Not prepared at all

DO NOT READ:

7 Don’t know / Not sure

9. Refused

4. [If Q4.2=1] Do you have an emergency plan for where you and your child(ren) will go and what to do in the event of a diseaster? [If Q4.2 NOT equal to 1]: Do you have an emergency plan for where you will go and what to do in the event of a disaster?

1 Yes [Go to Q4.6]

2 No [Go to Q4.8]

DO NOT READ:

7 Don’t know / Not sure

9 Refused

5. Does the plan include a list of phone numbers and designated out-of-town contacts?

1 Yes

2 No

DO NOT READ:

7 Don’t know / Not sure

10. Refused

6. Have you discussed this plan with the members of your household?

1 Yes

2 No

3 Not applicable, I Iive alone

4 Not applicable, the other members of my household are children too young to understand

[If Q4.2 NOT equal to 1, GOTO Q4.9]

1. Does at least one of the children in your household currently attend a school outside of your home, including day-care or part-time kindergarten?

1 Yes

2 No [GOTO Q4.9]

DO NOT READ:

7 Don’t know / Not sure [GOTO Q4.9]

9 Refused [GOTO Q4.9]

8. Are you aware of the details of the emergency or evacuation plan of the school or schools, including where the school plans to evacuate and how to get information about the child in the event of a disaster?

1 Yes

2 No

DO NOT READ:

7 Don’t know / Not sure

9 Refused

9. Does your household keep copies of important paper or electronic documents like birth certificates and insurance policies in a waterproof container, fireproof safe, or other safe place?

[CATI NOTE: if respondent has only electronic copies, a “safe place” would include a cloud server (e.g., iCloud, Google Drive, Dropbox, email, etc), or physical hardware such as a computer, external hard drive, or thumb drive kept in a safe place (e.g., waterproof container, fireproof safe)].

1 Yes

2 No

DO NOT READ:

7 Don’t know / Not sure

7. Refused

10. Does your household have a 3-day supply of water (besides tap) for everyone who lives there? A 3-day supply of water is 1 gallon of water per person per day.

1 Yes

2 No

DO NOT READ:

7 Don’t know / Not sure

9 Refused

11. Does your household have a 3-day supply of nonperishable food for everyone who lives there? By nonperishable we mean food that does not require refrigeration or cooking.

1 Yes

2 No

DO NOT READ:

7 Don’t know / Not sure

11. Refused

12. Does your household have a working battery operated radio and working batteries for your use if the electricity is out?

1 Yes

2 No

DO NOT READ:

7 Don’t know / Not sure

9 Refused

13. In your household or vehicle are you able to charge your cellphone if the electricity is out? This may include a car charger or portable batteries.

1 Yes

2 No

DO NOT READ:

7 Don’t know / Not sure

9 Refused

14. Does your household have a 7-day supply of prescription medication for each person who takes prescribed medicines?

1 Yes

2 No

3 No one in household requires prescribed medicine

DO NOT READ:

7 Don’t know / Not sure

9 Refused

[CATI NOTE: IF Q2.4 = 08, 09, 10, 11, 13; OTHERWISE END SURVEY]

15. Earlier you mentioned you use [insert pill, patch, ring, condom based on Q2.2 response]. How long will your current supply of this birth control method last?

[INTERVIEWER NOTE: IF RESPONDENT GIVES ONLY THE NUMBER OF PILL PACKS/PATCHES/RINGS/ CONDOMS SHE HAS, PROBE TO DETERMINE HOW LONG THAT NUMBER OF ITEMS WILL LAST.

READ ONLY IF NECESSARY:

1 less than 1 month

2 2 months (more than 1 month but less than 2 months)

3 3 months (more than 2 months but less than 3 months)

4 more than 3 months

DO NOT READ:

7 Don’t know/ Not sure

9 Refused

[CATI NOTE: IF Q2.2 = 08, 09, 10; OTHERWISE END SURVEY]

16. Do you have a backup method such as condoms to prevent pregnancy if you run out of your supply of [insert pill, patch, ring based on Q2.2 response]?

1 Yes

2 No

DO NOT READ:

7 Don’t know / Not sure

9 Refused