Form 0920-20MU Screening/Eligibility Form

Form Approved

OMB Control No.: 0920-0572

Expiration date: 08/31/2021

ATTACHMENT 1:

SCREENING INSTRUMENT FOR

IN-DEPTH INTERVIEWS

Segmentation Table

Audience Segment	Location	Quota
English as a second language (ESL) adults (parent)	Northeast	1
ESL adults	South	1
ESL adults (parent)	Midwest	1
ESL adults	West	1
Adults 65+	Northeast	1
Adults 65+	South	1
Adults 65+	Midwest	1
Adults 65+	West	1
Parents of children 0-17	Northeast	1
Parents of children 0-17	Northeast	1
Parents of children 0-17	South	1
Parents of children 0-17	South	1
Parents of children 0-17	Midwest	1
Parents of children 0-17	Midwest	1
Parents of children 0-17	West	1
Parents of children 0-17	West	1

Northeast = Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, Pennsylvania

South = Delaware, Maryland, Virginia, West Virginia, Kentucky, North Carolina, South Carolina, Tennessee, Georgia, Florida, Alabama, Mississippi, Arkansas, Louisiana, Texas, Oklahoma

Midwest = Ohio, Michigan, Indiana, Wisconsin, Illinois, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, Kansas

West = Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada, California, Oregon, Washington, Alaska, Hawaii

Screening/Eligibility Form for In-Depth Interviews

1. Are you comfortable with speaking and reading in English? [If not apparent from conversation to this point]

   1. Yes [ELIGIBLE; CONTINUE]

   2. No [INELIGIBLE; STOP]

   3. Don’t Know [INELIGIBLE; STOP]

2. Primarily, what language do you speak in your home?

   1. English [ELIGIBLE, MOVE TO QUESTION 3]

   2. Other, record _________ [ELIGIBLE, MOVE TO TABLE A]

   3. Don’t Know [INELIGIBLE; STOP]

3. What is your age? Record age

   1. Age 18–64 years [ELIGIBLE; CONTINUE TO TABLE B]

   2. Age 65+ [ELIGIBLE; CONTINUE TO TABLE C]

   3. Age <18 years [INELIGIBLE; STOP]

   4. Don’t Know [INELIGIBLE; STOP]

eligibilIty criteria (FOR ESL ADULTS)
What is your age? Record age		 Age ≥18 years [ELIGIBLE; CONTINUE]  Age <18 years [INELIGIBLE; STOP]  Don’t Know [INELIGIBLE; STOP]
Are you the parent of a child(ren) age 0-17 years?		 Yes [ELIGIBLE; RECRUIT AT LEAST 2; CONTINUE to Q6]  No [ELIGIBLE; RECRUIT UP TO 2; SKIP to Q7]  Refused [INELIGIBLE; STOP]
Are you the primary decision maker regarding your child or children’s health?		 Yes [ELIGIBLE; CONTINUE]  No [INELIGIBLE; STOP]
How confident are you filling out medical forms in English by yourself? Recruiter to read response options: Extremely, Quite a bit, Somewhat, A little bit, Not at all		 Extremely [INELIGIBLE; STOP]  Quite a bit [ELIGIBLE; RECRUIT A MIX]  Somewhat [ELIGIBLE; RECRUIT A MIX]  A little bit [ELIGIBLE; RECRUIT A MIX]  Not at all [ELIGIBLE; RECRUIT A MIX]
What is the highest level of education you have completed?		 High school diploma or less [ELIGIBLE; CONTINUE]  Some college or associates degree [ELIGIBLE; CONTINUE]  College degree [INELIGIBLE; STOP]  Master’s degree [INELIGIBLE; STOP]  JD or PhD [INELIGIBLE; STOP]
Have you participated in a focus group, interview, telephone survey, and/or online survey in which you were asked your opinions regarding a product, a service, or advertising within the past six months?		 No [ELIGIBLE; CONTINUE]  Yes [INELIGIBLE; STOP]
Do you work for: • a market research company • an advertising agency or public relations firm • the media (TV/radio/newspapers/magazines) • as a healthcare professional (doctor, nurse, pharmacist, dietician, etc.)		 Yes [INELIGIBLE; STOP]  No [ELIGIBLE; CONTINUE]
ELIGIBILITY CHECK:	 Yes  No		Date: Initials:      

eligibilIty criteria (FOR PARENTS OF CHILDREN AGE 0–17)
Are you the parent of a child(ren) age 0-17 years?		 Yes [ELIGIBLE; CONTINUE]  No [INELIGIBLE; STOP]  Refused [INELIGIBLE; STOP]
Are you the primary decision maker regarding your child or children’s health?		 Yes [ELIGIBLE; RECRUIT TO QUOTA]  No [INELIGIBLE; STOP]
How confident are you filling out medical forms by yourself? Recruiter to read response options: Extremely, Quite a bit, Somewhat, A little bit, Not at all		 Extremely [ELIGIBLE; RECRUIT A MIX]  Quite a bit [ELIGIBLE; RECRUIT A MIX]  Somewhat [ELIGIBLE; RECRUIT A MIX]  A little bit [ELIGIBLE; RECRUIT A MIX]  Not at all [ELIGIBLE; RECRUIT A MIX]
Have you participated in a focus group, intercept interview, telephone survey, and/or online survey in which you were asked your opinions regarding a product, a service, or advertising within the past six months?		 No [ELIGIBLE; CONTINUE]  Yes [INELIGIBLE; STOP]
Do you work for: • a market research company • an advertising agency or public relations firm • the media (TV/radio/newspapers/magazines) • as a healthcare professional (doctor, nurse, pharmacist, dietician, etc.)		 Yes [INELIGIBLE; STOP]  No [ELIGIBLE; CONTINUE]
ELIGIBILITY CHECK:	 Yes  No		Date: 65+Initials:      

eligibilIty criteria (FOR ADULTS AGE 65+)
How confident are you filling out medical forms by yourself? Recruiter to read response options: Extremely, Quite a bit, Somewhat, A little bit, Not at all		 Extremely [ELIGIBLE; RECRUIT A MIX]  Quite a bit [ELIGIBLE; RECRUIT A MIX]  Somewhat [ELIGIBLE; RECRUIT A MIX]  A little bit [ELIGIBLE; RECRUIT A MIX]  Not at all [ELIGIBLE; RECRUIT A MIX]
Which of the following best describes your health decision-making? Recruiter to read response options		 I usually make my own decisions about my health. [ELIGIBLE; CONTINUE]  I make most of my health decisions, but sometimes rely on family to make decisions for me. [ELIGIBLE; STOP]  I usually rely on family to make health decisions for me. [INELIGIBLE; STOP]
Have you participated in a focus group, intercept interview, telephone survey, and/or online survey in which you were asked your opinions regarding a product, a service, or advertising within the past six months?		 No [ELIGIBLE; CONTINUE]  Yes [INELIGIBLE; STOP]
Do you work for: • a market research company • an advertising agency or public relations firm • the media (TV/radio/newspapers/magazines) • as a healthcare professional (doctor, nurse, pharmacist, dietician, etc.)		 Yes [INELIGIBLE; STOP]  No [ELIGIBLE; CONTINUE]
ELIGIBILITY CHECK:	 Yes  No		Date: Initials:      

Good news, you are eligible to participate in this project.

If you agree to participate in this project, we will ask you to take part in a web-based telephone interview. We will ask a series of questions relating to emergency preparedness. This interview will take about 60 minutes. To thank you for your time, you will receive $50 for your participation.

Do you have any questions?

Would you like to participate in the interview?

 Yes (CONTINUE)

 No, Okay, thank you for your time today. (STOP HERE)

CONFIRM NAME, DEMOGRAPHICS, EMAIL, AND PHONE

1. Could you please spell your first and last name?

I have a few additional questions to ensure we get a good mix of participants in this evaluation.

2. What is your gender? [If not apparent from conversation to this point]

 Female

 Male

2. Which of the following best describes your ethnicity?

 Hispanic or Latino

 Not Hispanic or Latino

2. Which of the following best describes your race? Please select one or more as applicable.

 American Indian or Alaska Native

 Asian

 Black or African American

 Native Hawaiian or Other Pacific Islander

 White

2. What is the highest level of education you have completed? (Don’t ask again for ESL adults; pull from Q8)

 High school diploma or less

 Some college or associates degree

 College degree

 Master’s degree

 JD or PhD

2. What is the best number where you can be reached?

2. What is the best email address where you can be reached? As a reminder, this needs to be an email address that you use frequently.

2. How would you like us to contact you in the event we need to reach you (email or phone)?

1. [If phone] What is the best day and/or time to reach you via phone?

Participant Preferred COntact Information
PARTICIPANT NAME:
RACE:	HISPANIC (Y/N):
EDUCATION LEVEL:
LANDLINE:	CELL:
EMAIL (must be an email address that is used frequently):
Best time and way to reach:

Public reporting burden of this collection of information is estimated to average three 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 0920-0572