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 Validity study of intellectual and developmental disabilities questions recruited through newspaper advertisement/flyer
Dial respondent’s telephone number [hereafter referred to as R] as indicated on CCQDER voice mail system.
Note: Respondents will be directed to indicate on the voicemail recording if they are calling in for themselves or if they are a caregiver/LAR calling in for someone else.
Note: Speak only to R (the person who called). 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 and …
If R called in for themselves, go to Self-Report Intro
If R is a caregiver calling for someone else, go to Proxy Intro
Self-Report Intro:
***NOTE: If, at any time during the screening call, R’s consent capacity is in question, finish with exit script 1
...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 to answer some questions about health] / [looking for adults who have difficulties doing things in everyday life, like learning new things, solving problems, and making decisions]. 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 to self-report screener
Self-report Screener
1. Where did you see our advertisement/flyer? ___________________________________________________
2. How old are you? [If under age 18, go to exit script 2] ________________
A. Because of a physical, mental, or emotional problem, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? Would you say:
No – no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
B. Did you have difficulty learning in school or learning how to read or write? Would you say:
No – no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
C. Has a doctor, teacher, or other professional ever told you that you have a developmental disability or an intellectual disability?
No
Yes (specify disability/disabilities: ____________________________________ )
3. FOR INTERVIEWS CONDUCTED ONSITE AT NCHS-- Are you a U.S. citizen? [If No, go to exit script 3]
Yes
No
4. 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
5. Are you Spanish, Hispanic or Latino?
Yes
No
6. 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.
Self-Report 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 questions about health and how easy or hard it is for a person to do things in everyday life, like learning new things, solving problems, and making decisions. Then the interviewer will ask you to explain what you were thinking as you answered the questions. The interviewer will also ask 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 the 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 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? [If respondent with I/DD: Would you like to bring someone with you to the interview or do you want to come by yourself?]
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: Do you have a family member or any other person you would like to bring with you to the interview?
If yes: Is it OK if I contact that person to give them information about our study and confirm your eligibility? If R agrees, obtain contact information and skip to LAR Intro. If R doesn’t agree, continue to “If no or not sure” bullet point below.
If no or not sure: That’s ok. Can someone from my office call you back to talk more about the details of the study? If yes, confirm contact information and notify staff Interviewer, who will call to conduct formal assessment of consent capacity. If no, We appreciate your call and thank you for your interest in our study.
Exit script 2: 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 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 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: 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 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 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 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 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.
Legally Authorized Representative (LAR) Intro:
...Hello, my name is [CCQDER Recruiter/CCQDER Staff‘s name]. I am calling from the National Center for Health Statistics. I’m calling because a person under your care, [name of adult with I/DD], is interested in a survey research study we are conducting. Are you his/her legally authorized representative? If yes, continue. If no or not sure, Go to exit script 1. 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 the person under your care is 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 the information you provide for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you or the person you care for 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 to LAR screener
LAR Screener
1. How old is the person under your care? [If under age 18, go to exit script 2] ______________
A. Because of a physical, mental, or emotional problem, does he/she have difficulty doing errands alone such as visiting a doctor’s office or shopping? Would you say:
No – no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
B. Did he/she have difficulty learning in school or learning how to read or write? Would you say:
No – no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
C. Has a doctor, teacher, or other professional ever told you that he/she has a developmental disability or an intellectual disability?
No
Yes (please specify which disability or disabilities he/she has): ________________________
D. Are you willing and able to accompany him/her to an interview?
No [Go to exit script 3]
Yes
[If respondent has not met one of the eligibility criteria go to exit script 4]
2. FOR INTERVIEWS CONDUCTED ONSITE AT NCHS—Is he/she and are you a U.S. citizen? [If No, go to exit script 5]
Yes
No
3. What is the highest level of school he/she has completed?
Less than High School (No Diploma or GED)
High School Diploma or GED
Associate Degree
Some College
Bachelor’s Degree
Graduate Degree
4. Is he/she Spanish, Hispanic or Latino?
Yes
No
5. What race or races does he/she consider himself/herself 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 6]. Otherwise continue.
LAR Entry Script:
...Based on your answers to the questions so far, we would like to invite him/her to take part in our study. For this study we’d like him/her to come here to the National Center for Health Statistics in Hyattsville, Maryland/agreed mutual location. An interviewer will ask him/her a variety of questions about difficulties he/she may have doing day-to-day activities, like learning new things, solving problems, and making decisions. Then the interviewer will ask him/her to explain what he/she was thinking as he/she answered the questions. The interviewer will also ask about his/her opinions of the questions. His/her answers will help us find out if the survey questions will be easy for other people to answer. Everything he/she says will be kept private. With your permission, we would like to record the interview. The recording is a record of what we asked and what he/she said about the questions. Do you give permission to have his/her interview video recorded? Yes/No. [If no, ask if for permission to audio record]. Do you give permission to have his/her interview audio recorded? Yes/No. [If no, go to exit script 7. At a minimum audio recording is essential for this project].
We would also like to invite you to complete a similar interview, answering the questions in reference to the person under your care. The interview will take place at the same time as his/her interview and you both will be compensated $40 each. Are you interested in participating in your own interview? Yes/No
If Yes: Great!
If No: That’s ok. We would still like for him/her to participate and for you to accompany him/her to the interview.
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 8.]
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, we’ll need to speak with a legally authorized representative before we can go any further. Can you put me in touch with their legal authorized representative? If no, We won’t be able to use him/her at this time. We appreciate your call and thank you for your interest in our study.
Exit script 2: I’m sorry, he/she has to be 18 years of age or older take part in this study and therefore we won’t be able to use him/her at this time. We appreciate your call and thank you for your interest in our study.
Exit script 3: In order for him/her to participate in the study session, we need you to read and sign a consent form. The consent form tells you about the study, and what he/she is being asked to do as part of the study session. Would you like me to send the forms through the mail? I will need the completed forms back before the scheduled interview. The completed forms MUST be received by me before his/her scheduled interview. We prefer that you send back the completed forms by mail or deliver in person. You may also send the completed forms back through [name of respondent with I/DD] in a sealed envelope provided by us. However, if you send the completed forms back through him/her, you MUST be available by phone to verify that you have given permission for him/her to participate in the study session. If the completed forms are not received before the start of the interview, and in the case of completed forms being returned by [name of respondent with I/DD] you have not been reached to confirm permission for him/her to participate, he/she will not be allowed to participate in the study session and will not receive the $40. [Record method of getting the forms to the LAR: ___________________________________________________________________________________].
Exit script 4: I’m sorry, he/she has not met one of the eligibility requirements for this particular study. However, I would like to put his/her name and the information you gave me into our database so that I can contact you about other studies coming up in the future. Is that ok? If yes, record name & number. If no: OK, thank you for your time.
Exit Script 5: 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 this screening process would be complete. Would you be agreeable to having his/her interview conducted at an offsite location? If yes, discuss off-site interviewing locations. If no, Would it be okay if I added your telephone number and his/her name, 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 telephone number and his/her name and any information you gave me will not be added to our database.
Exit script 6: 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 telephone number and his/her name, 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 telephone number and his/her name and any information you gave me will not be added to our database.
Exit script 7: 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 him/her at this time. Would it be okay if I added your telephone number and his/her name, 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 telephone number and his/her name and any information you gave me will not be added to our database.
Exit script 8: 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 telephone number and his/her name, 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 telephone number and his/her name and any information you gave me will not be added to our database.
Proxy Intro:
...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 aimed at caregivers of an adult with an intellectual or developmental disability. 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 the person under your care meets eligibility criteria 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 the information you provide for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you or the person you care for 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 Proxy-report screener
Proxy-report Screener:
1. How old is the person under your care? [If under age 18, go to exit script 1] ______________
A. Because of a physical, mental, or emotional problem, does he/she have difficulty doing errands alone such as visiting a doctor’s office or shopping? Would you say:
No – no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
B. Did he/she have difficulty learning in school or learning how to read or write? Would you say:
No – no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
C. Has a doctor, teacher, or other professional ever told you that he/she has a developmental disability or an intellectual disability?
No
Yes (please specify which disability or disabilities he/she has): ________________________
[If respondent has not met one of the eligibility criteria go to exit script 2]
2. FOR INTERVIEWS CONDUCTED ONSITE AT NCHS—Are you a U.S. citizen? [If No, go to exit script 3]
Yes
No
3. What is the highest level of school he/she has completed?
Less than High School (No Diploma or GED)
High School Diploma or GED
Associate Degree
Some College
Bachelor’s Degree
Graduate Degree
4. Is he/she Spanish, Hispanic or Latino?
Yes
No
5. What race or races does he/she consider himself/herself 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.
Proxy 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 difficulties he/she may have doing day-to-day activities, like learning new things, solving problems, and making decisions. Then the interviewer will ask you to explain what you were thinking as you answered the questions. The interviewer will also ask about you 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 the 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 7. At a minimum audio recording is essential for this project].
We would also like to invite the person under your care to complete a similar interview, but answering the questions about his/her own experience of difficulties. The interview would take place at the same time as your interview, in a separate room, and you both will be compensated $40 each. Do you think he/she would be willing and able to participate in his/her own interview? Yes/No
If Yes: Can you put me in touch with him/her so I can do a brief screening and give him/her information about the interview? (Collect contact information. After proxy call, conduct self-report screener with this person)
If No: That’s ok. We would still like for you to participate in our study and do your own interview.
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 8.]
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, he/she has to be 18 years of age or older to meet eligibility criteria for 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, he/she has not met one of the eligibility requirements for this particular study. However, I would like to put his/her name and the information you gave me into our database so that I can contact you about other studies coming up in the future. Is that ok? If yes, record name & number. If no: OK, thank you for your time.
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 this 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 telephone number and his/her name, 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 telephone number and his/her name and any information you gave me will not be added to 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 added your telephone number and his/her name, 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 telephone number and his/her 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 intellectual and developmental disabilities questions
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 health and
difficulties you may have doing day-to-day activities, like learning
new things, solving problems, and making decisions. We 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...
Self-report Screener
1. How old are you now? [If under age 18, go to exit script 1] ________________
A. Because of a physical, mental, or emotional problem, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? Would you say:
No – no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
B. Did you have difficulty learning in school or learning how to read or write? Would you say:
No – no difficulty
Yes – some difficulty
Yes – a lot of difficulty
Cannot do at all
C. Has a doctor, teacher, or other professional ever told you that you have a developmental disability or an intellectual disability?
No [Skip to question 3]
Yes
D. Do you know what disability you were told you have?
No
Yes (specify: ___________________ )
[If respondent has not met one of the eligibility criteria go to exit script 2]
3. FOR INTERVIEWS CONDUCTED ONSITE AT NCHS-- Are you a U.S. citizen? [If No, go to exit script 3]
Yes
No
4. 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
5. Are you Spanish, Hispanic or Latino?
Yes
No
6. 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.
Self-Report 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 health and difficulties you may have doing day-to-day activities, like learning new things, solving problems, and making decisions. Then the interviewer will ask you to explain what you were thinking as you answered the questions. The interviewer will also ask 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 the 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 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.
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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, you have not met one of the eligibility requirements for this particular study. However, I would like to put your name and the information you gave me into our database so that I can contact you about other studies coming up in the future. Is that ok? If yes, record name & number. If no: OK, thank you for your time.
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 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: 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 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 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 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 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.
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| File Type | application/msword |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |