1 Active Duty/Veteran Women Screening Instrument

OMB No. 0990-0281

Exp. Date 09/30/2021

Screening Instrument for Active Duty and Veteran Women

Audience Segment	Age	No. of Groups	Location
Active Duty Women	18–40	1	San Diego, CA
		1	San Antonio, TX
	41–64	1	Virginia Beach, VA
		1	San Diego, CA
Veteran Women	18–40	2	San Antonio, TX
		2	Virginia Beach, VA
		2	San Diego, CA
	41–64	2	San Antonio, TX
		2	Virginia Beach, VA
		2	San Diego, CA

Section I: Screening

1. Have you ever served in the military (e.g., on active duty in the U.S. Armed Forces, Reserves, or National Guard)?

___ Yes (RECORD AND CONTINUE to 1b)

___ No (RECORD; THANK AND TERMINATE)

___ Prefer not to answer (RECORD; THANK AND TERMINATE)

1b. What is your service member or veteran status?

___ Active duty (RECORD AND CONTINUE)

___ Veteran (RECORD AND CONTINUE to 1c)

___ Reserves (RECORD; THANK AND TERMINATE)

___ National Guard (RECORD; THANK AND TERMINATE)

___ Prefer not to answer (RECORD; THANK AND TERMINATE)

2. What is your age?

___ Age 18–40 years (RECORD AND CONTINUE)

___ Age 41–64 years (RECORD AND CONTINUE)

___ Age <18 years or >65 years (RECORD; THANK AND TERMINATE)

___ Don’t know (RECORD; THANK AND TERMINATE)

3. Where do you go for health care? (READ ALL RESPONSES; RECORD ALL THAT APPLY)

___ Veterans Health Administration (VHA) provider(s) only (RECORD; THANK AND TERMINATE)

___ Military Health System (MHS) provider(s) only (RECORD; THANK AND TERMINATE)

___ Non-VHA/MHS provider(s) only (RECORD AND CONTINUE)

___ Combination of VHA/MHS and non-VHA/MHS providers (RECORD AND CONTINUE to 3b)

___ Don’t know (RECORD; THANK AND TERMINATE)

3b. What percentage of your health care do you get from non-VHA/MHS providers?

___ More than 50 percent (RECORD AND CONTINUE)

___ 50 percent or less (RECORD; THANK AND TERMINATE)

4. What is the highest degree or level of education you have completed? If currently enrolled, highest degree received. (RECRUIT MIX)

___ High school diploma or less

___ Some college

___ College degree

___ Post graduate studies or degree

5. What is your estimated annual household income? (RECRUIT MIX)

___ $25,000 or less

___ Between $25,000 - $49,000

___ Between $50,000 - $100,000

___ More than $100,000

6. Which of the following best describes your ethnicity? (READ ALL RESPONSE OPTIONS)

___ Hispanic or Latino (RECORD AND CONTINUE)

___ Not Hispanic or Latino (RECORD AND CONTINUE)

7. Which of the following best describes your race? (Please select one or more)

(READ ALL RESPONSE OPTION)

___ White (RECORD AND CONTINUE)

___ Black or African-American (RECORD AND CONTINUE)

___ American Indian or Alaska Native (RECORD AND CONTINUE)

___ Asian (RECORD AND CONTINUE)

___ Native Hawaiian or Other Pacific Islander (RECORD AND CONTINUE)

Section II: Informed Consent Form

Good news, you are eligible to participate in this project and we would like to invite you to participate in a focus group session! I’d like to go through the consent form now to make sure that I cover all aspects of the project and give you the opportunity to ask any questions you may have. Please feel free to interrupt me at any time if you have any questions.

Hager Sharp, an independent communications firm, is inviting you to participate in a 90-minute focus group to better understand veteran and active duty women’s experiences in receiving health care from providers outside of Veterans Health Administration (VHA)/Military Health System(MHS).

To decide if you want to be a part of this project, you should know enough about it to make an informed decision. This consent form goes over the project’s purpose, what is involved, and possible risks and benefits. Once you understand the project, you will be asked if you wish to participate; if so, we will obtain your written consent to participate.

Purpose of the Project

The purpose of this project is to understand active duty and veteran women’s experiences receiving care from health care providers outside of VHA/MHS. We will ask you questions about your facilitators and barriers, as well as your opinions on the health information, online tools, and resources that are most needed to support the physical and mental health of active duty and veteran women like you. This project is being conducted by the U.S. Department of Health and Human Services (HHS) Office on Women’s Health (OWH). Representatives from Hager Sharp will conduct the focus groups on behalf of OWH.

Description of Procedures

If you agree to participate in this project, you will be provided with a date, time, and location to take part in a small group discussion with 8-10 other active duty or veteran women. During this focus group, a skilled moderator will use a guide to lead all participants through a series of questions for discussion. The discussion will last about 90 minutes and will be audio and video recorded. To thank you for your time, you will receive a $75 cash compensation.

Risks

Some questions in this focus group deal with health issues and your military experience, and these questions may be upsetting to some people. You may choose to skip any question for any reason.

Benefits

There are no direct benefits to you as a participant in this project. However, your participation will help OWH understand active duty and veteran women’s experiences seeking care outside VHA/MHS, as well as help us determine the best health information tools needed to support the health of active duty and veteran women.

Confidentiality and Privacy

The information you give us will be kept private to the extent required by law. The personal information and identifiable information recorded to schedule the focus group will be kept with Hager Sharp. To protect your privacy, we will keep your discussion transcript under a code number instead of your name. The project staff will keep a link to you and your coded information that will be secured and available only to a limited number of staff. We will keep your records in locked files, and only project staff will be allowed to look at them. Your name and other facts that point to you (such as your email address and phone number) will never appear in any report or presentation.

Voluntary Participation and Withdrawal

You are free to choose not to take part in this project. You may stop participating at any time, for any reason. If you have questions about this project, if you would like to withdraw from this project, or if you think you have been harmed by this project, please contact Carolin Serafini at 202-706-7461 or [email protected].

Questions

We have used some technical terms in this form. Please feel free to ask about anything you don't understand. Please do consider this project and consent form carefully – as long as you feel is necessary – before you make a decision.

Do you have any questions?

Are you willing to participate?

___ Yes (CONTINUE)

___ No (RECORD; THANK AND TERMINATE)

Section III: Scheduling the Focus Group

The final step is to get you scheduled for the focus groups. Groups are scheduled for the following times (INSERT DATES AND TIMES), which of these options works best for you?

If after we hang up, if you have a question about the focus group or decide you can’t participate, please contact [INSERT NAME AND CONTACT INFO OF RECRUITER].

Now, can you please tell me the following information about yourself?

Name________________________________________________________________________

Mailing Address (include zip code) _________________________________________________

Email Address (must be an email address that is used frequently): __________________________________________________________________

Day Number_________________________ Evening Number____________________________

Mobile Phone (if available) ______________________

Preferred Contact (Email or Phone) ______________________

Public reporting burden of this collection of information is estimated to average 3 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 Office of the Chief Information Officer, Department of Health and Human Services, Sherrette Funn, [email protected] or (202) 795-7714; ATTN: PRA (xxxx-xxxx).