0920-0572 Screening Form

Form Approved

OMB Control No.: 0920-0572

Expiration date: 08/31/2021

Attachment 2 – Online Screening Form

Project: Opinions of Hand Hygiene Focus Group Discussion

Format: 60-minute in-person focus group discussion

Location: Atlanta, GA

[CONSULTING COMPANY] is conducting two focus groups with adult men and women to learn about opinions of health communication materials promoting hand hygiene behavior. In the focus groups we will discuss health communication materials that have been developed to promote hand hygiene behavior. Focus group findings will be used to help develop a health communication campaign focused on hand hygiene behaviors.

This informal discussion will last about 60 minutes and will be located in Atlanta, GA. Also, the discussions will be audio recorded.

You will not be asked to buy anything during the focus groups, we are only interested in your opinions. You will receive $40 as a token of appreciation for participating in this discussion. Also, we need to let you know that there will not be any childcare provided during the focus group discussion, so please make the appropriate childcare arrangements if you have children.

To determine if you are eligible to participate in the focus groups, we need to ask you a few questions. All of your responses will be kept private.

If you have any questions about the focus groups, please contact [INSERT POINT OF CONTACT AT CONSULTING FIRM].

1. Are you interested in participating in a 60-minute long, in-person focus group to talk about health communication materials to promote hand hygiene behavior?

Yes ……………………………………....	1
No ……………………………………....	2	[TERMINATE]
Preferred not to answer ……………………………………....	9

2. What is your sex?

Female ……………………………………....	1
Male ……………………………………....	2
Preferred not to answer ……………………………………....	9

3. Do you or does anyone else in your immediate family or household have a job in the following fields.

In marketing or communication ……………………………………....	1
In medicine or healthcare ……………………………………....	2
In a restaurant ……………………………………....	3	[TERMINATE]
In public health ……………………………………....	4
In education or childcare ……………………………………....	5
Preferred not to answer ……………………………………....	9
None of these fields ……………………………………....	6

4. May I ask if your age is in any of the following categories? Are you . . .

Under 18 years old ………………………………………	1	[TERMINATE]
18 – 24 ………………………………………	2
25 – 34 ………………………………………	3
35 – 44 ………………………………………	4
45 – 54 ………………………………………	5
55 – 64 ………………………………………	6
65 and older ………………………………………	7
Preferred not to answer ………………………………………	9	[TERMINATE]

How would you describe your racial/ethnic background?

5. Do you consider yourself Hispanic or Latino/a

No ….…………………………………...	1
Yes ….…………………………………...	2
Preferred not to answer ….…………………………………...	9

6. What is your race? (One or more categories may be selected)

White ….…………………………………...	1
Black or African American ….…………………………………...	2
American Indian or Alaska Native ….…………………………………...	3
Asian ….…………………………………...	4
Native Hawaiian or Other Pacific Islander ….…………………………………...	5
Preferred not to answer ….…………………………………...	9

7. What is your current relationship status? Are you…?

Single (e.g., single, divorced, widowed, separated) …………………………………………….................................	1
In a relationship (e.g., married, in domestic partnership, has girlfriend/boyfriend) …………………………………………….................................	2
Preferred not to answer …………………………………………….................................	9

8. What is your yearly individual income?

$0-$19,999 ………………………………………	1	[TERMINATE]
$20,000-$39,999 ………………………………………	2
$40,000-$59,999 ………………………………………	3
$60,000-$79,000 ………………………………………	4
$80,000-$99,999 ………………………………………	5
$100,000 or more ………………………………………	6	[TERMINATE]
Preferred not to answer ………………………………………	9

9. What is the highest level of education you have completed?

Less than high school ………………………………………	1	[TERMINATE]
Some high school, but not a graduate ………………………………………	2
High school graduate (or GED) ………………………………………	3
Some college/technical, not graduate ………………………………………	4
College graduate ………………………………………	5
Graduate school or higher ………………………………………	6	[TERMINATE]
Preferred not to answer ………………………………………	9

10. Are you a parent or primary caregiver to any children?

Yes ……………………………………....	1
No ……………………………………....	2
Preferred not to answer ……………………………………....	9

9. Do you prepare or cook food in your home at least one time per week?

Yes ……………………………………....	1
No ……………………………………....	2	[TERMINATE]
Preferred not to answer ……………………………………....	9

11. Do you currently live in the United States?

Yes ……………………………………....	1
No ……………………………………....	2	[TERMINATE]
Preferred not to answer ……………………………………....	9

12. What best describes where your primary residence is located?

Urban area …………………………………………….................................	1
Suburban area …………………………………………….................................	2
Rural area …………………………………………….................................	3
Preferred not to answer …………………………………………….................................	9

13. Have you ever used an alcohol based hand sanitizer (e.g. Purell, Germ-x, or other similar ones)?

Yes ……………………………………....	1
No ……………………………………....	2	[TERMINATE]
Preferred not to answer ……………………………………....	9

14. Where do you generally receive information about health (select all that apply)?

Friends and family ……………………………………....	󠆸
Coworkers ……………………………………....	󠆸
Medical settings (e.g., clinicians, nurses, doctors) ……………………………………....	󠆸
Online websites (e.g., WebMD, Mayo, CDC) ……………………………………....	󠆸
Social media (e.g., Facebook, Twitter, Instagram) ……………………………………....	󠆸
Online forums or message boards (e.g., Reddit) ……………………………………....	󠆸
Online videos ……………………………………....	󠆸
Paper flyers or pamphlets ……………………………………....	󠆸
Paper posters ……………………………………....	󠆸
Newspapers (either paper or digital) ……………………………………....	󠆸
Magazines (either paper or digital) ……………………………………....	󠆸
Television ……………………………………....	󠆸
Radio ……………………………………....	󠆸
Email ……………………………………....	󠆸

[TERMINATION PROMPT] Closing for Ineligible Participants:

Thank you for taking the time to answer these questions. You are not eligible to be in this study. There are many possible reasons why people are not eligible for the study. These reasons were decided earlier by the researchers. We value your interest in this research study. Thank you for being willing to participate. If you have any questions about the focus groups, please contact [INSERT POINT OF CONTACT AT CONSULTING FIRM].

[ELIGIBILITY PROMPT] Invitation Prompt:

Thank you for taking the time to answer these questions. You may be eligible to be in this study. A member of the research team will review your responses and will contact you if you are selected to participate. At that time they will provide you information on the date, time, and location of the interview.

As a reminder, we are talking to men and women as part of this research study to hear their opinions about health communication materials promoting hand hygiene behavior. This informal focus group discussion will last about 60 minutes and will be located in [LOCATION]. In the focus groups we will discuss health communication materials that have been developed to promote hand hygiene behavior. Also, the discussions will be audio recorded.

You will not be asked to buy anything during the focus groups, we are only interested in your opinions. You will receive $40 as a token of appreciation for participating in this discussion. Also, we need to let you know that there will not be any childcare provided during the focus group discussion, so please make the appropriate childcare arrangements if you have children.

15. Would you be interested in participating in this in-person focus group to talk about your opinions on health communication materials to promote hand hygiene behavior?

Yes ……………………………………....	1
No ……………………………………....	2	[TERMINATE]
Preferred not to answer ……………………………………....	9

[CONTACT INFORMATION PROMPT] Prompt to collect contact information

In order for us to let you know that you have been selected to participate the in the focus groups discussions, your contact information is needed.

Name
Phone (day)
Phone (evening)
Email
Best time to be reached by study team?

21. What is the best way for the study team to reach you?

Email …………………………………………….................................	1
Phone (day) …………………………………………….................................	2
Both …………………………………………….................................	3

Thank you for being willing to participate. If you have any questions about the focus groups, please contact [INSERT POINT OF CONTACT AT CONSULTING FIRM].

Public reporting burden of this collection of information is estimated to average 10 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