0920-0800 Screening Instrument AIAN

Form Approved

OMB No. 0920-0800

Exp. Date 10/31/2021

Attachment G:

Screening Instrument for

American Indian/Alaska Native

Young Women

Public reporting burden of this collection of information is estimated to average 3 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 (0920-0800)

Screening Instrument: American Indian/Alaska Native Women (For Recruiters in Tulsa and Philadelphia)

Hello, my name is ______________ and I am calling from _______________ a professional market research firm. I am not selling anything. We’re currently conducting focus groups for the Centers for Disease Control and Prevention.

Information from these discussions will be used to develop materials for young women about a health issue. May I ask you a few questions to see if you are eligible to participate in this project? This will take less than five minutes. [IF RESPONDENT INDICATES THAT THIS IS NOT A GOOD TIME, SCHEDULE A CALL BACK TIME]

1. Document gender. [ASK IF UNSURE]

_____ Female (CONTINUE)

_____ Male (THANK AND TERMINATE)

2. Which of the following best describes your ethnicity?

1. Hispanic or Latino (RECORD; THANK AND TERMINATE)

2. Not Hispanic or Latino (RECORD AND CONTINUE)

3. Which of the following best describes your race? Please select one or more as applicable.

1. American Indian or Alaska Native (RECORD AND CONTINUE)

2. Asian (RECORD; THANK AND TERMINATE)

3. Black or African American (RECORD; SWITCH TO SCREENER FOR AFRICAN AMERICAN WOMEN)

4. Native Hawaiian or Other Pacific Islander (RECORD; THANK AND TERMINATE)

5. White (RECORD; THANK AND TERMINATE)

4. How old are you? [READ RANGES]

_____ 17 years old or younger (THANK AND TERMINATE)

_____ 18-29 years (RECORD; CONTINUE)

_____ 30-44 years (RECORD; CONTINUE)

_____ 45 years old or older (THANK AND TERMINATE)

5. Think about both your mother and father’s side of the family. Include your parents, children, brothers/sisters, aunts/uncles, nieces/nephews, and grandparents.

Is there any history of breast or ovarian cancer in your family?

_____ Yes (RECORD; IF 18-29 YEARS OLD [Q2]; RECRUIT PER QUOTA; CONTINUE)

(RECORD; IF 30-44 YEARS OLD [Q2]; RECRUIT PER QUOTA; CONTINUE)

_____ NO (RECORD; IF 18-29 YEARS OLD [Q2]; RECRUIT PER QUOTA; CONTINUE)

(RECORD; IF 30-44 YEARS OLD [Q2]; RECRUIT PER QUOTA; CONTINUE)

6. Do you own a smart phone?

_____ Yes (CONTINUE)

_____ No (THANK AND TERMINATE)

7. Do you use the internet for at least 2 hours each week?

_____ Yes (CONTINUE)

_____ No (THANK AND TERMINATE)

8. Which of the following do you do multiple times per week?

[ ] Read email TERMINATE IF EMAIL-ONLY

[ ] Send email TERMINATE IF EMAIL-ONLY

[ ] Search using Google RECORD AND CONTINUE

[ ] Read news articles online RECORD AND CONTINUE

[ ] View Facebook timeline RECORD AND CONTINUE

[ ] Write Facebook posts/comments RECORD AND CONTINUE

[ ] View Twitter feed RECORD AND CONTINUE

[ ] Post tweets RECORD AND CONTINUE

[ ] Watch YouTube videos RECORD AND CONTINUE

[ ] Upload YouTube videos RECORD AND CONTINUE

[ ] Leave comments on YouTube RECORD AND CONTINUE

[ ] View photos online RECORD AND CONTINUE

[ ] Upload photos online RECORD AND CONTINUE

[ ] Read blogs RECORD AND CONTINUE

[ ] Write blog posts RECORD AND CONTINUE

[ ] Other: ____________________ RECORD AND CONTINUE

9. Do you or any member of your household work as an employee or contractor in any of the following areas?

_____  Public health, such as the Centers for Disease Control and Prevention (CDC), local or state health department, or other public health organization

_____ Medical professions, such in a health clinic; doctor or dentist’s office; hospital;

Medical laboratory or research institution; Health Insurance Company or agency; or pharmacy or pharmaceutical company

(IF “YES” TO ANY OF THE ABOVE, THANK AND TERMINATE)

10. Have you ever been diagnosed by a doctor with breast cancer or ovarian cancer?

_____ Yes (THANK AND TERMINATE)

_____ NO (RECORD AND CONTINUE)

11. Have you ever undergone genetic counseling with a licensed genetic counselor regarding cancer-related concerns? This does not include a conversation with a doctor or nurse.

_____ Yes (RECORD AND CONTINUE; RECRUIT MIX)

_____ NO (RECORD AND CONTINUE; RECRUIT MIX)

12. Have you ever undergone genetic testing related to cancer or your risk for developing cancer (such as testing for a BRCA1 or BRCA2 gene mutation) through a service like 23andMe or AncestryDNA?

_____ Yes (RECORD AND CONTINUE; RECRUIT MIX)

_____ NO (RECORD AND CONTINUE; RECRUIT MIX)

13. Have you ever undergone genetic testing related to cancer or your risk for developing cancer (such as testing for a BRCA1 or BRCA2 gene mutation) through a licensed genetic counselor?

_____ Yes (RECORD AND CONTINUE; RECRUIT MIX)

_____ NO (RECORD AND CONTINUE; RECRUIT MIX)

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

(RECRUIT A MIX; AT LEAST HALF MUST HAVE SOME COLLEGE OR MORE)

01 High School Diploma or less (RECORD; RECRUIT A MIX; CONTINUE)

02 Some college or associates degree (RECORD; RECRUIT A MIX; CONTINUE)

03 College degree (RECORD; RECRUIT A MIX; CONTINUE)

04 Master’s degree (RECORD; RECRUIT A MIX; CONTINUE)

05 JD or PhD (RECORD, RECRUIT A MIX; LIMIT 1 PER GROUP; CONTINUE)

15. What is your marital status?

______Currently married or in a legal/state registered domestic partnership

______ Not Married (may include divorced, widowed, separated, and never married)

(RECORD; RECRUIT A MIX OF MARRIED/NOT MARRIED; CONTINUE)

16. Do you have children?

_____ Yes (RECORD AND CONTINUE)

If so, record how many children, their sexes, and ages: ____________

_____ NO (RECORD AND CONTINUE)

(RECORD; RECRUIT A MIX OF MOTHERS/NOT MOTHERS; CONTINUE)

17. What is your estimated annual household income? (RECORD; RECRUIT A MIX)

_____ $25,000 or less

_____ Between $25,000 - $49,000

_____ Between $50,000 - $100,000

_____ More than $100,000

ASSESS AND VERIFY ABILITY TO SPEAK AND UNDERSTAND ENGLISH

Those are all of my questions. You qualify and we would like to invite you to participate in a focus group. The discussion will last about 90 minutes and will be audio and video recorded. In appreciation for your time, you will be given $75 after completing the focus group. It’s important to know that none of the information you provide us during the focus group will ever be linked to your name in any way.

Are you willing to participate?

_____ Yes (CONTINUE)

_____ NO (THANK AND TERMINATE, ASK IF THEY CAN SUGGEST A PEER THAT MAY BE INTERESTED)

Groups are scheduled for the following times (INSERT DATES AND TIMES – OFFER AT LEAST ONE EVENING GROUP), which of these works with your calendar?

Prior to the start of the focus group, you will receive information for the focus group. If after we hang up, if you have a question about the focus group or decide you can’t participate, please contact me at___________________.

Now, can you please tell me the following information about yourself?

Name________________________________________________________________________

Mailing Address (include zip code) _________________________________________________

Email Address__________________________________________________________________

Day Number_________________________ Evening Number____________________________

Mobile Phone (if available) ______________________ Fax (if available) __________________

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