Form
Approved OMB
No. 0923-17IY Exp.
Date xx/xx/201x
Ask the participant these questions before beginning the interview.
Script: I’m going to ask you some questions about Burmese people you know in the Milwaukee area. Not including people you live with, think about how many adults (18 years and older) you see and talk with regularly.
Of Burmese people you see and talk with regularly, about how many eat fish caught in the bodies of water that we talked about?
______ people ___ Don’t know ___ Refused
How many of these people would you consider referring to a project like this one?
______ people ___ Don’t know ___ Refused
If there are people you would not refer to this project, why would you not refer them? Read list of reasons.
Check all that apply.
___ [They already participated]
___ [They work so are unable to come to the events]
___ [I don’t know where they live]
___ Other Specify: __________________________________
___ Don’t know ___ Refused
If the participant is not a seed: What is your relationship to the person who gave you the coupon?
___ Friend or acquaintance
___ Co-worker
___ Store owner or employee
___ Other Specify: __________________________________
___ Don’t know ___ Refused
If the participant is not a seed: Would you have considered referring (name of recruiter), the person who referred you?
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).
___ Yes ___ No ___ Don’t know ___ Refused
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | wdw0 |
File Modified | 0000-00-00 |
File Created | 2021-01-21 |