Form 0920-0932 Viajo sin Zika Online Focus Group Screener - English

_{Information Collection to Assess the Viajo sin Zika Awareness Communication Campaign for Hispanics/Latinos Visiting Friends and Relatives}

Gen-IC

Information Collection for Evaluation of Education, Communication, and Training (ECT) Activities for Mobile Populations

OMB No. 0920-0932

Expiration Date 05/31/2021

Submitted on: August 6, 2018

Attachment D: Online Focus Group Screener

Appendix D

Viajo sin Zika Online Focus Group Screener

Introduction

ICF, a consulting firm, is conducting online group discussions on behalf of the US Centers for Disease Control and Prevention (CDC). The purpose of these discussions is to get feedback on educational efforts to help the public reduce their risk of Zika when traveling abroad.

These group discussions will take about 1 hour. Those who are selected to participate will be given a $10 Amazon gift card as a thank you for participating in the group.

Please complete the following questions to determine your eligibility.

Questions

1. Are you 18 - 44 years old?

   • Yes

   • No [Ineligible – see ineligible statement on page 2]

2. Would you describe yourself as either Hispanic or Latino?

   • Yes

   • No [Ineligible – see ineligible statement on page 2]

3. Where do you currently live?

   • New York City

   • Los Angeles

   • Orlando

   • Other [Ineligible – see ineligible statement on page 2]

4. Where were you born?

   • United States

   • Dominican Republic [skip to Q6]

   • Puerto Rico [skip to Q6]

   • Mexico [skip to Q6]

   • Nicaragua [skip to Q6]

   • Another country in Latin America/ the Caribbean – specify country _______ [skip to Q6]

   • None of the above

5. Do you have a parent who was born in one of these countries? [Select all that apply]

   • Dominican Republic

   • Puerto Rico

   • Mexico

   • Nicaragua

   • Another country in Latin America/ the Caribbean – specify country _______

   • None of the above [Ineligible – see ineligible statement on page 2]

6. Have you traveled to the country of your birth (or parent’s birth) within the past 5 years?

   • Yes

   • No

7. Do you plan to travel to the country of your birth (or parent’s birth) in the next 12 months?

   • Yes

   • No [Ineligible if response to Q6 is also negative – see ineligible statement on page 2]

8. Have you heard of or seen the Viajo sin Zika campaign?

   • Yes

   • No [Ineligible – see ineligible statement on page 2]

9. Do you have access to a computer with Internet that you can use to participate in an online group discussion?

   • Yes

   • No [Ineligible – see ineligible statement on page 2]

Eligibility Statements

ELIGIBLE: Based on your responses, you are eligible to participate in the group discussion. Are you interested in participating in a 60-minute online group discussion about CDC’s efforts to educate the public about Zika?

• If no: Thank you for your time.

• If yes: Thank you, we have just a few more questions to ask you.

10. What gender is stated on your birth certificate?

• Male

• Female

• Prefer not to answer

11. What gender do you currently identify with?

• Male

• Female

• Other

• Prefer not to answer

12. Do any of the following descriptions apply to you? Select all that apply.

• I am a pregnant woman

• I am woman who is trying to get pregnant in the next year

• I am a man with a partner who is pregnant or trying to get pregnant in the next year

• I have a female family member who is pregnant or trying to get pregnant in the next year

• None of the above

• Prefer not to answer

13. What was your total household income before taxes during the past 12 months?

• Less than $25,000

• $25,000 to $34,999

• $35,000 to $49,999

• $50,000 to $74,999

• $75,000 to $99,999

• $100,000 or more

• Prefer not to answer

14. What is your education level?

• Completed some high school

• High school graduate

• Completed some college

• Associate degree

• Bachelor's degree

• Completed some postgraduate

• Master's degree

• Ph.D., law or medical degree

• Other advanced degree beyond a Master's degree

• Prefer not to answer

15. Which language are you most comfortable speaking during the group discussion?

• English

• Spanish

• Please provide an email address and/or phone number to reach you. Someone from ICF, the consulting firm working with CDC to lead these discussions, will be in contact with you to set up a date and time for the discussion:

  • Email address: ______

  • Phone number: ______

INELIGIBLE: Unfortunately, you are not eligible to participate. However, you can learn how to prevent Zika when traveling abroad by visiting the Viajo sin Zika website at: https://www.cdc.gov/viajosinzika/index.html

Thank you for your interest. We appreciate your time and willingness to help.

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