0920-0572 Men Aged 65 and Older Screener

Form Approved

OMB Control No.: 0920-0572

Expiration date: 8/31/2021

_Sepsis Educational Effort – Recruitment Screener

Consumers – Men aged 65+ with one or more chronic condition or disease Version

Hello. My name is ____________ and I work for [recruiting firm]. We are working with ICF, a consulting firm in Atlanta, Georgia, and the Centers for Disease Control and Prevention (CDC) to conduct in-person focus groups to gather feedback on educational materials on a specific health topic. The focus groups will include four to seven other people and will last about 75 minutes.

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

• Yes

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

May I ask you a few questions in order to determine whether you are a good fit to participate in the interview?

• Yes

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

NOTE TO RECRUITER: Please terminate individuals as soon as they provide a response that makes them ineligible for participation. Please use the termination script below:

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

For those who are eligible for participation, move on to the next question.

Record and keep all screened data.

1. What is your sex?

• Male

• Female (Thank person for their time, terminate, and end the conversation)

• Did not provide a response (Do not read as a response option; thank person for their time, terminate, and end the conversation)

2. What is your age? __________ [Recruiter to document actual age and then categorize]

• <18 years old (Thank person for their time, terminate, and end the conversation)

• 18-64 (Thank person for their time, terminate, and end the conversation)

• 65+

3. Do you live in TBD city?

   • Yes

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

4. This discussion will involve speaking and reading in English. Are you comfortable with that? 

• Yes  

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

5. Has a healthcare professional ever diagnosed you with a chronic medical condition or disease? 

• Yes 

• No (Thank person for their time, terminate, and end the conversation.)

• Don’t know (Proceed to 6)

6. Has a healthcare professional ever told you that you have one of the following chronic conditions or diseases? 

(Recruiter to read list) 

Arthritis	Yes	No	Don’t know	Prefer not to answer
Cancer	Yes	No	Don’t know	Prefer not to answer
Chronic Kidney Disease	Yes	No	Don’t know	Prefer not to answer
Chronic Obstructive Pulmonary Disease	Yes	No	Don’t know	Prefer not to answer
Diabetes	Yes	No	Don’t know	Prefer not to answer
Heart Disease	Yes	No	Don’t know	Prefer not to answer
Immunosuppression	Yes	No	Don’t know	Prefer not to answer
Stroke	Yes	No	Don’t know	Prefer not to answer
OTHER: __________

(If the individual says “No” to all options read, thank person for their time, terminate, and end the conversation.)

7. Do you work in a healthcare facility as a healthcare professional, paramedical professional, or health educator?

• Yes (Thank person for their time, terminate, and end the conversation)

• No

• Prefer not to answer (Do not read as a response option; thank person for their time, terminate, and end the conversation)

 

NOTE TO RECRUITER: Please check final eligibility determination (check all that apply to confirm)

Men aged 65 and older with one or more chronic condition or disease

• Male

• 65+ years old

• Currently lives in one of the following TBD cities

• Speaks and reads English at a level necessary for participation

• Diagnosed by a healthcare professional with one or more of the following chronic medical conditions or diseases: arthritis, cancer, chronic kidney disease, chronic obstructive pulmonary disease, diabetes, heart disease, immunosuppression, and/or stroke

• Does NOT work in a healthcare facility as a healthcare professional, paramedical professional, or health educator

If the individual is not eligible based on any of the above, go to termination script.

For those who are eligible for participation, move on to the next question.

8. Thank you for answering those questions. You are eligible to participate in the discussion. We will provide a $XX token of appreciation for participating in this discussion. Are you still interested in participating?

• Yes

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

I’m glad that you’re willing to participate! I have just a couple of additional questions and then will need to find the best time to schedule the discussion.

NOTE TO RECRUITER: Questions 9-14 do not effect eligibility.

9. Would you describe yourself as Hispanic or Latino?

• Yes

• No

• Did not provide a response (Do not read as a response option)

10. How would you describe your racial background? Please select all that apply.

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or other Pacific Islander

• White

• Other: _______________ (Do not read as a response option)

• Did not provide a response (Do not read as a response option)

11. What geographic area(s) would you say you live in? Please select only one.

    • Rural

    • Suburban

    • Urban

    • Don’t Know

12. What is your highest education level completed? Please select only one.

• Less than high school graduate/some high school

• High school graduate (or equivalent)

• Associate or technical degree

• Four-year college degree

• Master’s degree

• Professional or doctoral degree (MD, PhD, JD, etc.)

13. How confident are you filling out medical forms by yourself?

• Extremely

• Quite a bit

• Somewhat

• A little bit

• Not at all

14. Ok, let’s check your availability for the focus group discussion. Are you available at any of the following dates and times?

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

[If no times work] Record alternate times below. Otherwise, thank person for their time, terminate, and end the conversation.

Date: _________________Time: ___: ___ am/pm 

Date: _________________Time: ___: ___ am/pm 

Date: _________________Time: ___: ___ am/pm 

[If at least one time works for an in-person focus group] Thank you. We will send you an invitation with the address and instructions to arrive at the focus group facility at least 15 minutes before your scheduled time. Now, please confirm the following contact information:

Name
Mailing Address
Home Phone
Cell Phone
Email

We will send you a confirmation notification via email, mail, and/or mobile device. The day before the focus group, we will call to remind you about this focus group and will send a reminder via text message. After the focus group is over, we will send your token of appreciation 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 discussion. Otherwise, we’ll look forward to seeing you on [Month/Day/Year] at [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