Form 0920-0840 Recruitment Screener

Form Approved

OMB No. 0920-0840

Expiration Date: 10/31/2021

Virtual Focus Groups with Primary Care Physicians and OBGYNs:
Attitudes about Proposed Hepatitis C Screening Guidelines
DVH 2019

Generic Information Collection under Formative Research and Tool Development OMB #0920-0840

Attachment #3

Recruitment Screener

Privacy Act Statement:

This information is collected under the authority of the Public Health Service Act, Section 301, "Research and Investigation," (42 U.S.C. 241); and Sections 304, 306 and 308(d) which discuss authority to maintain data and provide assurances of confidentiality for health research and related activities (42 U.S.C. 242 b, k, and m(d)). This information is also being collected in conjunction with the provisions of the Government Paperwork Elimination Act and the Paperwork Reduction Act (PRA). This information will only be used by the Centers for Disease Control and Prevention (CDC) staff to inform activities of the Division of Viral Hepatitis (DVH).

Public reporting burden of this collection of information is estimated to average 10 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: OMB-PRA (0920-0840)

RECRUITMENT SCREENER
Virtual Focus Groups with Primary Care Physicians and OBGYNs:
Attitudes about Proposed Hepatitis C Screening Guidelines
DVH 2019

Text for telephone screening:

Hello. My name is __________ and I’m calling from Reckner. You indicated that you are interested in participating in a virtual focus group. We have an upcoming group to discuss your practices and opinions regarding screening guidelines. The group will be conducted by KRC Research. The sponsor of this group is the Centers for Disease Control and Prevention.

CDC is not interested in any personal details. We will be asking you a few questions to ensure we are recruiting a mix of people; but this information will not be shared with anyone.

INTERVIEWER INSTRUCTION: If respondent expresses concern at any point during the interview, please note their concern and discuss with the sponsor. Remind them that their answers and participation will be completely confidential.

Name: _______________________________________________________

Address: _______________________________________________________

City, State, Zip: _______________________________________________________

Phone: _______________________________________________________

Email: _______________________________________________________

Recruiter: _______________________________________________________

SEPARATE THIS CONTACT SHEET FROM THE REST OF THE SCREENER

AND SHRED AT THE END OF THE STUDY.

Screening questions to be read or filled out online.

RECORD GENDER:

Female	
Male	

What is your medical specialty? [READ LIST]

Family Physician	
General Internist	
General Practitioner	
Med-Peds (Internal Medicine & Pediatrics)	
Obstetrician/Gynecologist If OB/GYN, confirm they are actively practicing obstetrics.	 
Other (Please Specify)	

3. Do you have a subspecialty? [If yes] What is it? [RECORD ON LINE BELOW:

Yes	
No	

4. What year did you complete medical school? ___________________

5. What was the name of your medical school? ____________________

6. What year did you complete your residency? ___________________

7. Is your primary responsibility direct patient care?

Yes	
No	

8. On average, how many hours per week do you spend in direct patient care? _________

9. Do you work or are you affiliated with any of the following?

State or local government agency such as Public Health Department	
Federal government agency, such as the Veterans Administration	
Academic Institution	
Private Corporation such as Pharmaceutical Companies, Research Lab	

10. Which best describes your practice setting?

Solo practice	
Single specialty group practice	
Multi-specialty group practice	
Staff Model Health Maintenance Organization or HMO	
Other model HMO, Managed Care Organization	
Network managed care systems such as PPOs	
Mixed model practice	
Hospital-based practice	
Locum Tenens or temporary physician employment	
Practice seeing patients in a Hospital, Rehab or Nursing home	
Other: SPECIFY______________________________	

11. Do you accept Medicaid?

Yes	
No	

12. How many times within the past 6 months have you participated in a focus group or one-on-one interviews related to your professional expertise? [DON’T READ RESPONSE CATEGORY]

None	
1 or more	

INVITATION

Thank you for answering all of my questions. We would like to invite you to participate in a virtual focus group discussion with other physicians. The purpose is to discuss screening guidelines and how they are used in everyday practice. The discussion will last approximately 75 minutes.

You will receive [$100] as a token of appreciate for your participation, which we will provide to you in the form or a check or gift card after your participation in the group.

The groups are virtual, meaning that you can participate from the comfort of your home or office, but you will need to be in front of a computer with internet access so you can review information, as well as on a telephone. We advise all focus group participants to use a landline and have reliable internet connection. To better simulate an in-person group, you will need to be visible to the other participants via web camera. If you do not have a video camera on your computer that streams images in real time or a webcam, we will send you an external one. We can call you before the group to help you get set up with the webcam and make sure all the technology needed for the discussion is working properly.

This study is for research purposes only, and all of your feedback during the group will be confidential, reported in the aggregate only. To preserve the integrity of your remarks for accurate reporting, the discussion will be recorded.

Is this something you are interested in and comfortable with?

Yes	
No		THANK AND TERMINATE

Great! I’m going to read you the times and dates we have open. Please let me know which ones works best with your schedule. [INSERT SCHEDULE]

Do you have a video camera or webcam on your computer that streams images in real time?

Yes	
No	

We will send a confirmation letter confirming the details.

If you have any questions, please call the physician recruiting coordinator for this research at

1-866-386-6163 extension 499.