Screening Script

Form Approved

OMB No. 0920-0222

Exp. Date xx/xx/20xx

Attachment D

Template 1

Respondent recruited from newspaper advertisement

Sample screening script for respondent contact by CCQDER Recruiter/CCQDER Staff

Person for cognitive testing and evaluation of [FILL]

recruited through newspaper advertisement/flyer

CDC estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, SD-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0222).

We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347).

REVIEWERS: NOTE THAT THE FOLLOWING IS A PROTOTYPE SCRIPT THAT IS GENERALLY FOLLOWED BY THE CCQDER RECRUITER/CCQDER STAFF FOR PLACING RETURN CALLS TO POTENTIAL RESPONDENTS WHO HAVE RESPONDED TO OUR RECRUITMENT ADVERTISEMENT BY LEAVING THEIR NAME AND A DAY TIME PHONE NUMBER ON OUR VOICE MAIL SYSTEM. THE CCQDER RECRUITER/CCQDERSTAFF DEPARTS FROM THIS AS APPROPRIATE, GIVEN THE NATURE OF THE PARTICULAR STUDY BEING CONDUCTED.

Dial respondent’s telephone number [hereafter referred to as R] as indicated on CCQDER voice mail system.

• Note: Speak only to R. If the number is answered by voice mail, call back at another time.

• CCQDER Recruiter/CCQDER Staff: Good morning/afternoon, may I speak to (name)?

• If R is not available or not at home, say, “Thank you” and try again at another time.

• If the person who answered the phone (NOT R) asks, “Who is calling?” or “What’s this about?” say, “I am returning their call to me. I’ll try to reach them at another time.

• If R has been successfully contacted, continue...

...Hello, my name is [CCQDER Recruiter/CCQDER Staff name]. I am calling from the National Center for Health Statistics. You may remember that you responded to an advertisement we placed in the [name of newspaper] on [date] or flyer looking for people to answer some questions about [FILL]. Is this a safe time to talk? If you are driving, I will call you back. I can also call you back if you are too busy.

• Wait for acknowledgment, such as, “This is a safe time to talk.”

• ...In order to determine if you are eligible for our study, I’ll need a few minutes of your time to ask some background questions. Answering these questions is completely voluntary. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent. Is this a good time to ask the questions or should I call back later?

• If not a good time to talk, schedule a time to call back.

• If good time to talk, continue...

Note: Additional questions may be asked which are specific to the project for which the respondent is being recruited.

1. Where did you see our advertisement?

_____________________________________

2. How old are you? [If under age 18, go to exit script 1].

________

3. What is the highest level of school you have completed?

 Less than High School (No Diploma or GED)

 High School Diploma or GED

 Associate Degree

 Some College

 Bachelor’s Degree

 Graduate Degree

4. Are you Spanish, Hispanic or Latino?

 Yes

 No

5. What race or races do you consider yourself to be? You may indicate more than one race.

 White

 Black or African American

 Asian

 American Indian or Alaska Native

 Native Hawaiian or Other Pacific Islander

If the recruitment needs for certain demographic groups have been achieved, go to exit script 2. Otherwise continue.

Entry Script:

...Based on your answers to the questions so far, we would like you to take part in our study. For this study we’d like you to come here to the National Center for Health Statistics in Hyattsville, Maryland/agreed mutual location. An interviewer will ask you a variety of questions about [fill topic(s)]. Then the interviewer will ask you to explain what you were thinking as you answered the questions. The interviewer will also ask you about your opinions of the questions. Your answers will help us find out if the survey questions will be easy for other people to answer. Everything you say will be kept private. With your permission, we would like to record your interview. The recording is a record of what we asked and what you said about the questions. Do you give permission to have your interview video recorded? Yes/No. [If no, ask if for permission to audio record]. Do you give permission to have your interview audio recorded? Yes/No. [If no, go to exit script 3. At a minimum audio recording is essential for this project].

Do you have any questions at this point? Pause to answer questions. If (not/you have no other questions), then let’s get you on the schedule, ok? We will be interviewing (Day, Month/Date) through (Day, Month/Date) from 8 a.m. to 6 p.m. Looking at your schedule, when would you be available to participate? Schedule. [If date/times not available go to exit script 4.]

A reminder call will be made to you a few days in advance. Should you have any questions or need to change your appointment, please feel free to contact me [name] at [phone number]. Thank you for responding to our ad, and I look forward to seeing you here at (DATE/TIME) Get respondent to cite date & time if possible.

---------------------------------------------------------

Exit script 1: I’m sorry, you have to be 18 years of age or older take part in this study and therefore we won’t be able to use you at this time. We appreciate your call and thank you for your interest in our study.

Exit script 2: Based upon your answers, it seems that we may already have a number of volunteers with very similar answers to yours. At this point we need to talk with people with some different characteristics. However, if we have cancellations or other slots open up, I may wish to call you back. Would it be okay if I kept your name, telephone number, and the information you provided in response to the eligibility questions until the end of this study? If yes, make notation. If no, Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.

Exit script 3: I’m sorry, willingness to be audio recorded is required in order to take part in this study and therefore we won’t be able to use you at this time. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.

Exit script 4: I see...ok, we were hoping to complete this particular study between (Month/Date) and (Month/Date), so it looks like we won’t be able to schedule you at this time. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, add to database. If no: OK, thank you for your time. Your name and any information you gave me will not be added to our database.

Form Approved

OMB No. 0920-0222

Exp. Date xx/xx/20xx

Attachment D – Template 2

Respondent recruited from CCQDER Respondent Database

Sample screening script for respondent contact by CCQDER Recruiter/CCQDER Staff

Person for cognitive testing and evaluation of [FILL]

recruited through CCQDER Respondent Database

CDC estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, SD-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0222).

We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347).

REVIEWERS: NOTE THAT THE FOLLOWING IS A PROTOTYPE SCRIPT THAT IS GENERALLY FOLLOWED BY THE CCQDER RECRUITER/CCQDER STAFF FOR PLACING RETURN CALLS TO POTENTIAL RESPONDENTS WHO HAVE RESPONDED TO OUR RECRUITMENT ADVERTISEMENT BY LEAVING THEIR NAME AND A DAY TIME PHONE NUMBER ON OUR VOICE MAIL SYSTEM. THE CCQDER RECRUITER/CCQDER STAFF DEPARTS FROM THIS AS APPROPRIATE, GIVEN THE NATURE OF THE PARTICULAR STUDY BEING CONDUCTED.

Dial respondent’s telephone number [hereafter referred to as R] as indicated in the CCQDER Respondent Database.

• Note: Speak only to R. If the number is answered by voice mail, call back at another time.

• CCQDER Recruiter/CCQDER Staff: Good morning/afternoon, may I speak to (name)?

• If R is not available or not at home, say, “Thank you” and try again at another time.

• If the person who answered the phone (NOT R) asks, “Who is calling?” or “What’s this about?” say, “I am returning their call to me. I’ll try to reach them at another time.

• If R has been successfully contacted, continue...

...Hello, my name is [CCQDER Recruiter/CCQDER Staff name]. I am calling from the National Center for Health Statistics. You may remember that you participated in a research study back in [date] testing questions on [topic]. Is this a safe time to talk? If you are driving, I will call you back. I can also call you back if you are too busy.

• Wait for acknowledgment, such as, “This is a safe time to talk.”

…We are in the process of testing a variety of questions about [FILL] and wondered if you might be interested in participating.

• If R indicates they are interested in participating continue…

• If R indicates they are NOT interested in participating, go to exit script 1.

• ...In order to determine if you are eligible for our study, I’ll need a few minutes of your time to ask some background questions. Answering these questions is completely voluntary. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent. Is this a good time to ask the questions or should I call back later?

• If not a good time to talk, schedule a time to call back.

• If good time to talk, continue...

Note: Additional questions may be asked which are specific to the project for which the respondent is being recruited.

1. How old are you now? [if under age 18, go to exit script 2]

________

2. What is the highest level of school you have completed?

 Less than High School (No Diploma or GED)

 High School Diploma or GED

 Associate Degree

 Some College

 Bachelor’s Degree

 Graduate Degree

3. Are you Spanish, Hispanic or Latino?

 Yes

 No

4. What race or races do you consider yourself to be? You may indicate more than one race.

 White

 Black or African American

 Asian

 American Indian or Alaska Native

 Native Hawaiian or Other Pacific Islander

If the recruitment needs for certain demographic groups have been achieved, go to exit script 3. Otherwise continue.

Entry Script:

...Based on your answers to the questions so far, we would like you to take part in our study. For this study we’d like you to come here to the National Center for Health Statistics in Hyattsville, Maryland/agreed mutual location. An interviewer will ask you a variety of questions about [fill topic(s)]. Then the interviewer will ask you to explain what you were thinking as you answered the questions. The interviewer will also ask you about your opinions of the questions. Your answers will help us find out if the survey questions will be easy for other people to answer. Everything you say will be kept private. With your permission, we would like to record your interview. The recording is a record of what we asked and what you said about the questions. Do you give permission to have your interview video recorded? Yes/No. [If no, ask if for permission to audio record]. Do you give permission to have your interview audio recorded? Yes/No. [If no, go to exit script 4. At a minimum audio recording is essential for this project].

Do you have any questions at this point? Pause to answer questions. If (not/you have no other questions), then let’s get you on the schedule, ok? We will be interviewing (Day, Month/Date) through (Day, Month/Date) from 8 a.m. to 6 p.m. Looking at your schedule, when would you be available to participate? Schedule. [If date/times not available go to exit script 5.]

A reminder call will be made to you a few days in advance. Should you have any questions or need to change your appointment, please feel free to contact me [name] at [phone number]. Thank you for responding to our ad, and I look forward to seeing you here at (DATE/TIME) Get respondent to cite date & time if possible.

---------------------------------------------------------

Exit script 1: I see...ok. Would it be okay if I kept your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? If yes, keep in database. If no: OK, thank you for your time. Your name and any information you gave me will be deleted from our database.

Exit script 2: I’m sorry, you have to be 18 years of age or older to take part in this study and therefore we won’t be able to use you at this time. We appreciate your call and thank you for your interest in our study.

Exit script 3: Based upon your answers, it seems that we may already have a number of volunteers with very similar answers to yours. At this point we need to talk with people with some different characteristics. However, if we have cancellations or other slots open up, I may wish to call you back. Would it be okay if I kept your name, telephone number, and the information you provided in response to the eligibility questions until the end of this study? If yes, make notation. If no, Would it be okay if I kept your name, telephone number, age, educational level, and race in our database so that I can contact you about other studies coming up in the future? If yes, keep in database. If no: OK, thank you for your time. Your name and any information you gave me will be deleted from our database.

Exit script 4: I’m sorry, willingness to be audio recorded is required in order to take part in this study and therefore we won’t be able to use you at this time. Would it be okay if I kept your name, telephone number, age, educational level, and race in our database so that I can contact you about other studies coming up in the future? If yes, keep in database. If no: OK, thank you for your time. Your name and any information you gave me will be deleted from our database.

Exit script 5: I see...ok, we were hoping to complete this particular study between (Month/Date) and (Month/Date), so it looks like we won’t be able to schedule you at this time. Would it be okay if I kept your name, telephone number, age, educational level, and race in our database so that I can contact you about other studies coming up in the future? If yes, keep in database. If no: OK, thank you for your time. Your name and any information you gave me will be deleted from our database.