Form 0920-0572 HMTS Evaluation Screener

Form Approved

OMB #:0920-0572

Expiration Date: 08/31/2021

Evaluation of Emergency Use Fact Sheets Regarding Medical Countermeasures

Screener with Programming Notes

Version 10-22-2018

PROGRAMMER:

• Program all questions on a new screen.

• Program progresses through the questioning in a “one-way” manner; participants should not be able to return to questions after they have answered them.

• Responses to all questions are voluntary; if respondent does not answer a question, the respondent should stay on the same page and be shown the “MISSING ANSWER(S)” validation, after which they should be allowed to move to the next page. If any of the screener questions are missing after validations, please terminate.

• Include one additional variable in the dataset not shown in this document: Respondent_ID (a unique identifier).

• If ineligible, please show THANK AND TERMINATE MESSAGE on NEW SCREEN:

“Thank you for your time. You do not qualify to participate in the current survey. Please continue to check for opportunities to participate in research through FieldGoals.”

[INTRO TEXT]

Thank you for your interest in participating in this project. Please make sure to answer all of the following questions during this initial screening process to determine if you are eligible to participate in this project.

1. Medical. Do you have any medical or public health training?

[SINGLE PUNCH]

Yes, I am a medical doctor. 01

Yes, I am a doctor of osteopathic medicine. 02

Yes, I am a physician assistant. 03

Yes, I am a nurse practitioner. 04

Yes, I am a nurse. 05

Yes, I am a pharmacist. 06

Yes, I am a dentist. 07

Yes, I am a public health professional (e.g., epidemiologist, 08

health communicator, health educator)

Yes, I have attended/am currently in school for any of the above. 09

No 10

[IF Medical=01–09, THEN INELIGIBLE. THANK AND TERMINATE.]

2. Research. When, if ever, was the last time you participated in a marketing/research study interview or focus group?

[SINGLE PUNCH]

Within the past three months 01

More than three months ago 02

Never 03

[IF Research=01, THEN INELIGIBLE. THANK AND TERMINATE.]

3. Age. What is your age?

[OPEN-END NUMERICAL]

years old

[SCHEDULING QUOTA FOR AGE]

Age Category	Scheduling Quota
18–34	25
35–64	47
65 or Older	18

4. ETH. Are you of Hispanic or Latino origin?

[SINGLE PUNCH]

Yes, I am of Hispanic or Latino origin 01

No, I am not of Hispanic or Latino Origin 02

5. RACE. What is your race? (Mark one or more races to indicate what you consider yourself to be.)

[MULTI PUNCH]

American Indian or Alaska Native 01

Asian 02

Black or African American 03

Native Hawaiian or Other Pacific Islander 04

White 05

[SCHEDULING QUOTA FOR COMBINED RACE/ETH]

Race/Ethnicity Category	Scheduling Quota (Schedule no more than):
Asian	4
Black or African American	14
Hispanic or Latino	18
White	54

6. Sex. What is your sex?

[SINGLE PUNCH]

Male 01

Female 02

[SCHEDULING QUOTA FOR GENDER]

Sex Category	Scheduling Quota:
Male	47
Female	48

7. Zip. What is your zip code?

[OPEN-END NUMERICAL]

[SCHEDULING QUOTA FOR ZIP]

Urbanicity Category	Scheduling Quota:
Urbanized areas (50,000 or more people)	64
Urban Clusters (at least 2,500 and less than 50,000 people)	8
Rural (all other areas not defined as above)	18

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

[SINGLE PUNCH]

Less than high school 01

High school graduate 02

Some college but no degree 03

Associate degree 04

Bachelor’s Degree 05

Advanced or postgraduate degree 06

[SOFT SCHEDULING QUOTA FOR EDUCATION]

Education Category	Scheduling Quota (Schedule no more than):
Less than high school	11
High school graduate	52
Bachelor’s degree	27

9. Child Caregiver. Are you a parent of a child under the age of 18 who lives in your household at least part-time?

[SINGLE PUNCH]

Yes 01

No 02

10. Elderly Caregiver. Do you provide assistance or support for an individual above the age of 65 at least 1 day per week or for activities that equate to approximately 8 hours of care?

[SINGLE PUNCH]

Yes 01

No 02

[SOFT SCHEDULING QUOTA FOR CAREGIVER]

Caregiver Category	Scheduling Quota:
Parents	36
Caregiver for elderly	13
Not a caregiver	41

11. Health Lit.¹ How confident are you filling out medical forms by yourself?

[SINGLE PUNCH]

Extremely 01

Quite a bit 02

Somewhat 03

A little bit 04

Not at all 05

HEALTH LITERACY LEVEL	Response
Limited	Not at all A little bit
Adequate	Somewhat
High	Quite a bit Extremely

[SOFT SCHEDULING QUOTA FOR HEALTH LIT]

Health Literacy Category	Scheduling Quota (Schedule no more than):
Limited	32
Adequate	58

12. Income. Which of the following categories best describe your total, annual household income?

[SINGLE PUNCH]

Under $20,000/year 01

$20,001 - $30,000/year 02

$30,001 - $40,000/year 03

$40,001 - $50,000/year 04

$50,001 - $60,000/year 05

$60,001 - $80,000/year 06

$80,001 - $100,000/year 07

Over $100,000/year 08

[SOFT SCHEDULING QUOTA FOR INCOME]

Income Category	Scheduling Quota:
Under $20,000/year - 30,000/year	30
$30,001 - $80,000/year	30
$80,001 and above	30

[IF INELIGIBLE DISPLAY (THANK AND TERMINATE)]

Thank you for your time. You do not qualify to participate in the current survey. Please continue to check for opportunities to participate in research through FieldGoals.

[DISPLAY IF ELIGIBLE]

You are eligible to participate in the current project. Please continue to the next screen to provide your contact information and a member of the FieldGoals team will reach out to you to schedule your interview.

1 Haun, J., Luther, S., Dodd, V., & Donaldson, P. (2012). Measurement variation across health literacy assessments: implications for assessment selection in research and practice. J Health Commu,17 Suppl 3:141-59. doi: 10.1080/10810730.2012.712615.

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