National Firefighter Registry

Attachment D

Form Approved

OMB No. 0920-0572

Expiration Date 8/31/2021

Potential Survey Tool Questions

This is the entire universe of potential questions that we may use from the Health Message Testing System Question Bank. Not all the questions will be used in each tool and the focus groups will help clarify the final selection.

Q) I am a

professional/career firefighter

volunteer firefighter

pay-for-call firefighter

other ____________________

16c. Have you heard about the National Firefighter Registry?

Yes

No

If yes, describe it in a few words. ____________________________________

17c. What can you tell me about firefighters and cancer?

A very big problem

A problem

Not a problem

Not sure

16d. Is this message believable?

• Yes • No

The public reporting burden of this collection of information is estimated to average 2 hours 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).

A. Are you willing to provide personal medical information about your life to the government, knowing the information is secure and will never be released?

B. INSERT message 2 from Ad

C. INSERT message 3 from Ad

D. INSERT message 4 from Ad

22d. Did you think any of these ads was effective to motivate you or someone else to [INSERT health behavior/message/phrase]?

• Yes • No

26d. Do you see yourself doing this...or something like it? Why/why not?

29d. Is there anything you want to know that this item does not tell you?

30d. If you saw or heard this message, would it get your attention? Why or why not?

41d. What makes it hard to do this?

56d. What are the good things about trying this tactic?

57d. What makes it hard to do this?

69d. Where do you get your information about [INSERT health topic or behavior]?

71d. What are some of the ways you have gotten information about [INSERT health topic or behavior] prior to today? [Probe: role of media, word-of-mouth, other.]

74d. When it comes to [INSERT health topic or behavior], are there any organizations that you would really trust as a reliable source of information?

91d. Who do you think would be a good spokesperson to use to convince you and your friends to [INSERT health topic or behavior]?

101d. Have you ever heard of an organization called the Centers for Disease Control and Prevention or CDC?

102d. What if the CDC was to say something like this? Would that change the way you look at these statements? Would it make any of them more or less believable? More or less appealing? Motivating?

103d. What if the CDC and [INSERT partner name] said something like this? Would that change the way you look at these statements? Would it make any of them more or less believable? More or less appealing? Motivating?

125d. In general, are you aware of [INSERT description of program, campaign, or web site]?

• Yes

• No
• Don’t Know/Not Sure • Refused

79d. How could this information be conveyed more effectively?

77e. The message that I saw about [INSERT health condition/behavior/disease/syndrome/injury/ disability] was compelling.

78e. The message about [INSERT health condition/behavior/ disease/syndrome/injury/disability] was persuasive.

79e. The message was dumb. 80e. The message was weak.

7f. Do you plan to [INSERT health topic or behavior]?

42f. I feel as though I can make a difference regarding [INSERT health topic or behavior].

43f. The suggestions for dealing with [INSERT health topic or behavior] made in the message are doable.

44f. I personally could do the suggested [INSERT health topic or behavior] in the message.

45f. Helping improve [INSERT health topic or behavior] is a goal within my reach.

46f. I am confident that I can protect myself from [INSERT health topic or behavior].

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Are you willing to provide personal medical information about your life to the government, knowing the information is secure and will never be released?

Yes

No

If no, what would it take to convince you to sign-up for the National Firefighter Registry.

1a. Gender:

• Male

• Female

2a. In which of the following categories does your age fall:

• under 18 years of age

• 18-24 years of age

• 25-34 years of age

• 35-44 years of age

• 45-54 years of age

• 55-64 years of age

• 65-74 years of age

• 75 years of age or older

4a. What is the highest level of education you have completed?

• Grade school

• Less than high school graduate/some high school

• High school graduate or completed GED

• Some college or technical school

• Received four-year college degree

• Some post graduate studies

• Received advanced degree

• Other: _____________________

8a. In what state, city, and zip code do you currently live?

City _______________________ State ____________________ Zip _____________

12a. What is your marital status?

• Married

• Unmarried living with a partner

• Divorced

• Widowed

• Separated, or

• Single, never been married

13a. Which of the following categories best describe your total, annual household income?

• Under $20,000/year

• $20,001 - $30,000/year

• $30,001 - $40,000/year

• $40,001 - $50,000/year

• $50,001 - $60,000/year

• $60,001 - $80,000/year

• $80,001 - $100,000/year

• Over $100,000/year

14a. Number of children (under age 18) living in the household: • None

• 1-2 children

• 3-4 children

• 5 or more children

5a. Please tell me your race or ethnic background. Do you consider yourself?

Ethnicity:

Are you Hispanic or Latino? Yes or No

Race:

• White/Caucasian

• Black or African-American

• American Indian or Alaska Native

• Native Hawaiian or Other Pacific Islander

• Asian

33a. Do you now smoke cigarettes every day, some days, or not at all? Every day

• Some days

• Not at all

35a. About how long has it been since you completely quit smoking cigarettes?

_____ Days _____ Weeks _____ Months _____ Years

44a. Do you have Cancer? Yes or No

45a. For how long have you had cancer? _________________