Sample Screener

DGMQ Training, Education, and Communication Needs Assessment – International Travelers Screener

Sample screener for Surveys, Focus Groups, or Interviews

International Travelers

Hello, my name is ____________________ from ____________________. I am calling on behalf of the Centers for Disease Control and Prevention (CDC).

We are calling to find out if you would be interested in joining a [focus group discussion] on health and international travel. We are not trying to sell you anything. The group will last about 2 hours and you will be compensated for your time. Is now a good time for you to answer a few questions to find out if you qualify and are interested in participating in the group discussion? [If yes, continue]

(Record Gender) [Confirm if unsure: And you are (female/male?)] [Recruit a mix]

a. Female ____ [CONTINUE]

b. Male ____ [CONTINUE]

1. Which of the following categories best describes your age? [Recruit a mix]

Younger than 18…………………………………..1 [THANK/END]

19–24…….………………………………………..2 [CONTINUE]

25–35…….……………………………………......3 [CONTINUE]

36–45…….………………………………………..4 [CONTINUE]

46–59.……….………………………………….....5 [CONTINUE]

60+ ……….………………………………….…....6 [CONTINUE]

2. Are you a U.S. citizen or permanent resident?

Yes………………………………….1 [CONTINUE to question 4]

No…………………………………..2 [go to question 3]

3. What is your native, or first, language? [Recruit at least half who report a language other than English as native.]

Yes………………………………….1 [CONTINUE]

No…………………………………..2 [CONTINUE]

4. Do you currently have health insurance?

Yes………………………………….1 [CONTINUE]

No…………………………………..2 [CONTINUE]

5. Do you or does anyone in your household work for a healthcare organization as a doctor, nurse, or other healthcare provider?

Yes………………………………….1 [IF YES, THANK/END]

No…………………………………..2 [CONTINUE]

6. Have you been paid to participate in a focus group or other group discussion in the past 6 months?

Yes………………………………….1 [THANK/END]

No…………………………………..2 [CONTINUE]

7. Other than Canada, have you traveled outside of the United States in the last 2 years?

Yes………………………………….1 [CONTINUE]

No…………………………………..2 [THANK/END]

8. In what year did you take your most recent trip? ____________ [If more than 2 years, [THANK/END]

9. Which of the following places have you traveled either for work or for personal reasons, or a combined trip during the last 2 years? [Recruit a mix.]

Africa.…………………………………….1 [CONTINUE]

Asia……………………………………….2 [CONTINUE]

Central America…………………………..3 [CONTINUE]

Middle East……………………………….3 [CONTINUE]

Europe…………………………………….4 [CONTINUE]

Australia…………………………………..5 [CONTINUE]

South & West Pacific Islands……………..6 [CONTINUE]

South America……….……………………7 [CONTINUE]

10. Which category best describes how frequently you travel internationally?
[Recruit a mix]

More than four times per year….…..……..…1 [CONTINUE]

Two to four times per year ………….….…...2 [CONTINUE]

Once a year …………………………..…...…3 [CONTINUE]

Once every 2 years…………………..……….4 [CONTINUE]

11a. Would you describe yourself as…[READ AND RECORD]

a. Hispanic or Latino/Latina ____

b. Not Hispanic or Latino/Latina ____

11b. Next, would you describe yourself as… [READ AND RECORD]

a. American Indian or Alaska Native ____

b. Asian or Asian American ____

c. Black or African American or African ____

d. Native Hawaiian or Pacific Islander ____

e. White or Caucasian ____

12. What is the highest level of education you have completed?
[CONTINUE TO INVITATION]

Less than high school graduate
High school graduate/GED
Some college
College degree
Graduate or professional degree

INVITATION

Thank you for answering all of my questions. We would like to invite you to participate in a general discussion with other travelers to discuss health and international travel issues.

This discussion will take place on Monday, _______, at our offices, located ________.

Times: Group 1______5:30 pm

Group 2______7:30 pm

The discussion will last approximately 2 hours. We will also provide snacks and beverages.

Would you be willing to participate? Yes____ [CONTINUE] No____ [THANK/END]

Now, let me just verify the spelling of your name and your address, so we can send you a confirmation letter with directions to our offices. [RECORD RESPONDENT’S INFORMATION]

Name:______________________________________Telephone:________________________

Address:_____________________________________________________________________

City, State:____________________________________________Zip:____________________

E-mail:____________________________________________________

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