Screener - LTC Med tech/sitter

Form Approved

OMB Control No.: 0920-0572

Expiration date: 8/31/2021

Sepsis Campaign – Recruitment Screener

Healthcare Professional (HCP) Version – Long Term Care Medical Technicians and Sitters

Hello. My name is ____________ and I work with [recruiting firm]. We are working with ICF, a consulting firm in Atlanta, Georgia, and the Centers for Disease Control and Prevention (CDC) to gather feedback from healthcare professionals to inform a health education initiative. The interview will be online and will last approximately 60 minutes.

Do you think that you might be interested in participating in this type of interview?

• Yes

• No (Thank person for their time and end conversation)

Would you mind if I ask you a few questions in order to determine whether or not you are a good fit to participate in the interview?

• Yes

• No (Thank person for their time and end conversation)

NOTE TO RECRUITER: Please continue through all questions, until specified, before letting individuals know that they cannot be invited to participate at this time based on at least one of the responses they provided. Record and keep all screened data.

1. Are you currently employed as a health care professional assisting your residents/patients with one or more of the following types of care: bathing, dressing, toileting, walking, transferring in and out of bed, assisting with meals, obtaining vital signs, monitoring behaviors and habits, and/or assisting nurses in distributing medication(s)?

• Yes – (Please tell me the title of your role: ____________________)

• No (Thank person for their time, read termination script (below), and end conversation)

Termination Script

“We appreciate your willingness to answer each of the questions. Unfortunately, you do not meet all of the required criteria to participate in the interview. Thank you for your time.”

Public reporting burden of this collection of information is estimated to average 5 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

2. Are you currently employed as a [insert job title from question #1] at a long-term care facility, such as a nursing home, long-term acute care center, adult day care center, or dementia facility?

• Yes

• No (Thank person for their time, read termination script, and end conversation)

3. What state do you currently work in?

• Illinois

• Louisiana

• Mississippi

• New Jersey

• New York

• Ohio

• Pennsylvania

• Tennessee

• West Virginia

• None of the above (Thank person for their time, read termination script, and end conversation)

4. What is your age?

• 18-64 (Please specify: ___)

• 65+ (Thank person for their time, read termination script, and end conversation)

5. Do you read and speak English fluently?

• Yes

• No (Thank person for their time, read termination script, and end conversation)

6. Do you have access to a phone, computer, and reliable internet to participate in the discussion?

• Yes

• No (Thank person for their time, read termination script, and end conversation)

7. Thank you for answering those questions. You are eligible to participate in the interview. For participating you will receive $XX as a token of appreciation. Are you still interested in participating?

• Yes

• No (Thank person for their time, read termination script, and end conversation)

8. I’m glad that you’re willing to participate! I just have a couple more questions to ask you. How would you describe the geographic area where you work?

   • Rural

   • Suburban

   • Urban

   • Don’t Know

9. What is your highest level of education?

• High School Degree/GED

• Associates Degree

• Bachelors Degree

• Masters Degree

10. How many years have you been working in your current role?

• <1 year

• Between 1-5 years

• >5 years

11. Do you currently hold a certification to assist with patient care?

• Yes

• No

12. What is your gender identification?

• Male

• Female

• Prefer not to say

13. Would you describe yourself as Hispanic or Latino?

• Yes

• No

• Prefer not to say

14. How would you describe your racial background? (Select all that apply)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or other Pacific Islander

• White

• Other: _______________

• Prefer not to answer

15. Are you available at any of the following dates and times?

*Actual dates and timeslots TBD – dependent on moderator/CDC availability.

[If at least one time works] Thank you. We will send you an invitation with a link to join the interview online and a telephone number to call in. Please join online AND dial in at your scheduled time. Now, can you please confirm your name, mailing address, your home telephone number, cell phone number, and a valid email address?

Name
Mailing Address
Home Telephone
Cell Phone
Email

We will send reminders about this interview via email, home phone, and/or mobile device. We will send your token of appreciation after the interview is over to the mailing address you provided.

Thank you for your time. Please contact [Recruiter] at [Phone Number] if you have questions or if your plans change and you are no longer able to participate in the interview. Otherwise, we’ll look forward to talking with you on [Month/Day/Year] at [Time].