0920-0222 Screeners

Attachment 3a – Telephone Screening Script – Respondent recruited from newspaper advertisement/flyer

Form Approved

OMB No. 0920-0222

Exp. Date: 08/31/2021

Notice - 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, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0222).

Assurance of confidentiality - 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).

Sample screening script for respondent contact by Collaborating Center for Questionnaire Design and Evaluation Research (CCQDER) Recruiter/CCQDER Staff for cognitive testing and evaluation of NHIS Questions on Adult Behaviors and CCQDER Questions on Opioids recruited through newspaper advertisement/flyer

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‘s name. I am calling from the National Center for Health Statistics. You may remember that you responded to the advertisement we placed in the [name of newspaper] on [date] or flyer looking for adults 18 years or older [who walk during the day, who smoke cigarettes fairly regularly, who used to smoke fairly regularly, who have had CT scans and/or x-rays of the chest area, and who have taken prescription opioid pain killers in the last 12 months]. 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...

1. Where did you see our advertisement/flyer?

___________________________________________________

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

3. During the past 7 days, did you walk for transportation or for any other reason?

 Yes

 No

4. In your life, have you ever smoked cigarettes?

 Yes

 No

4a. IF YES to 4: Do you currently smoke cigarettes fairly regularly?

 Yes

 No

4b. IF NO to 4a: Have you ever smoked cigarettes fairly regularly?

 Yes

 No

5. In the last 12 months, have you had an x-ray or CT scan of your chest area?

• Yes

• No

6. During the past 12 months, have you taken any opioid pain relievers prescribed by a doctor or dentist?  Examples include hydrocodone, Vicodin, Norco, Lortab, oxycodone, OxyContin, Percocet and Percodan.  Please do not include over-the-counter pain relievers such as aspirin, Tylenol, Advil, or Aleve.

• Yes

• No

6a. IF YES: About how long have you been taking or did you take the painkillers?

 Less than 3 months

 Between 3 months and a year

 More than a year

7. FOR INTERVIEWS CONDUCTED ONSITE AT NCHS-- Are you a U.S. citizen? [If No, go to exit script 2]

• Yes

• No

8. 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

9. Are you Spanish, Hispanic or Latino?

 Yes

 No

10. 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 walking, sleeping, smoking, CT scans and x-rays of the chest area, and prescription opioid painkillers. 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’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: I’m sorry, all Federal Government facilities require screening procedures for non U.S. citizens. This process can take more than 30 days. Unfortunately, our study has to be completed before your screening process would be complete. Would you be agreeable to having your interview conducted at an offsite location? If yes, discuss off-site interviewing locations. 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: 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 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 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 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 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.

Attachment 3b – Telephone Screening Script – Respondent recruited from CCQDER Respondent Database

Form Approved

OMB No. 0920-0222

Exp. Date: 08/31/2021

Notice - 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, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0222).

Assurance of confidentiality - 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).

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

Person for cognitive testing and evaluation of NHIS Questions on Adult Behaviors and NCHS Questions on Opioids recruited through CCQDER Respondent Database

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 walking, sleeping, smoking, CT scans and x-rays of the chest area, and prescription opioid painkillers 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...

1. Where did you see our advertisement/flyer?

___________________________________________________

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

3. During the past 7 days, did you walk for transportation or for any other reason?

 Yes

 No

4. In your life, have you ever smoked cigarettes?

 Yes

 No

4a. IF YES to 4: Do you currently smoke cigarettes fairly regularly?

 Yes

 No

4b. IF NO to 4a: Have you ever smoked fairly regularly?

 Yes

 No

5. Have you ever had an x-ray or CT scan of your chest area?

• Yes

• No

6. During the past 12 months, have you taken any opioid pain relievers prescribed by a doctor or dentist?  Examples include hydrocodone, Vicodin, Norco, Lortab, oxycodone, OxyContin, Percocet and Percodan.  Please do not include over-the-counter pain relievers such as aspirin, Tylenol, Advil, or Aleve.

• Yes

• No

6a. IF YES: About how long have you been taking or did you take the pain killers?

 Less than 3 months

 Between 3 months and a year

 More than a year

7. FOR INTERVIEWS CONDUCTED ONSITE AT NCHS-- Are you a U.S. citizen? [If No, go to exit script 2]

• Yes

• No

8. 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

9. Are you Spanish, Hispanic or Latino?

 Yes

 No

10. 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 4.] 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 walking, sleeping, smoking, CT scans and x-rays of the chest area, and prescription opioid painkillers. 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 5. 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 6.]

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: I’m sorry, all Federal Government facilities require screening procedures for non U.S. citizens. This process can take more than 30 days. Unfortunately, our study has to be completed before your screening process would be complete. Would you be agreeable to having your interview conducted at an offsite location? If yes, discuss off-site interviewing locations. 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: 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 5: 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 6: 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.

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