Adolescent Screener - English

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Public reporting burden of this collection of information is estimated to average 5 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-xxxx).

Attachment E-4. Adolescent Screener - English

Table of Contents

Interviewer will read Introduction and Assent (Appendix F-5) 1

Past 12 Months TBI 2

Variables used in Programming:

CALLTYPE denotes if the sample is for a landline or cell phone number

1 = LANDLINE

2 = CELL

INTTYPE denotes who the interview is being conducted with

A = Adult, non-parent interview

P = Proxy interview with adult

D = Direct adolescent interview

NOTE: All responses in caps will not be read to the respondent. They are for interviewer coding only.

Interviewer will read Introduction and Assent (Appendix F-5)

ask if SPST2=1

ADOL1. Hello, my name is ____ calling on behalf of the Centers for Disease Control and Prevention. We’re conducting a nationwide study about head injuries in children and adults.

You may have heard about head injuries, especially those experienced by children who play sports.

Even if you haven’t had an injury in the past 12 months, you can still participate in this important study. We have asked your parents to give their permission for you to participate; they have said “yes.” However, even though your parents said “yes,” you can still say “no” and not participate. And you can skip any question or stop the survey at any time. The majority of respondents will complete the survey in less than 8 minutes.

There are minimal risks, and no known direct benefits to being in this voluntary study. CDC will keep the information that you provide private and secure to the extent permitted by the law. Your name will never be connected to your answers. We will not share your answers with your parents.

If you have questions or concerns about participating in the study, you may contact ICF International, the independent health research company hired to conduct this survey. They can be reached toll-free at -1-844-604-4399. If you have any questions about your rights as a research participant, please contact Sophia Zanakos at 301-572-0239. This call may be monitored for quality assurance purposes.

May we begin?

01. YES [SKIP TO TRANS1]

02. NO

ASK IF CALLTYPE =2

SAFE. Your safety is important. Are you driving in a car, or in a place where talking on the phone might distract you or jeopardize your safety or confidentiality?

01 YES

02 NO

99 REFUSED [TERMINATE, ASSIGN DISPO]

ASK IF CALLTYPE=2 AND SAFE=01

UNSAFE. I would like to call you at a more convenient time. What day and time would be best?

01 SCHEDULE CALLBACK

99 REFUSED [TERMINATE, ASSIGN DISP]

Past 12 Months TBI

ask if inttype = a, p, or d

When adult or proxy reports for child display: “Now I'd like to ask some questions about your [insert age/sex of child] child.”

RECALL. We are interested in learning about times, in the last year, when [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] experienced a head injury. This might have been from a bump, blow or jolt to [IF INTTYPE=A OR D READ “your”/ IF INTTYPE=P READ “their”] head.

1. CONTINUE

ASK if inttype=a, p or d

INJ. In the last year, that is since [insert date 1 year ago from today], [IF INTTYPE=A OR D READ “were you”/ IF INTTYPE=P READ “was your child”] examined in a doctor’s office, clinic, hospital or elsewhere because of a head injury?

01. YES

02. NO

97. DON’T KNOW

99. REFUSED

ASK if inttype=a, p or d and INJ =1

INJN. Since [insert date 1 year ago from today], how many head injuries did [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] have that caused [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] to go to a doctor’s office, clinic, or hospital or to be examined elsewhere?

ENTER COUNT: ______[0-96]

97. DON’T KNOW

99. REFUSED

ASK if inttype=a, p or d

PREJOG. Now I’d like for you to think about (IF YES TO TREATED TBI “other”) times in the last year when [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] may have experienced an injury to the head. I would like you to tell me about a head injury even if [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] did not go to see a doctor for care. This might have happened while playing a sport for fun or competition, or while [IF INTTYPE=A READ “you were”/ IF INTTYPE=P READ “your child was”] doing something physically active like bicycling. It might have happened as a result of a car accident or because someone hurt [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”]. Or, it could have happened because [IF INTTYPE=A READ “you”/ IF INTTYPE=P READ “your child”] tripped, slipped, or fell down.

1. CONTINUE

ASK if inttype=a, p or d

INJ2. In the last year, that is since [insert date 1 year ago from today], did [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] experience any other injuries to [IF INTTYPE=A OR D READ “your”/ IF INTTYPE=P READ “their”] head that you did not see a doctor about?

01. YES

02. NO

97. DON’T KNOW

99. REFUSED

ASK if inttype=a, p or d and INJ2 =1

INJN2. Since [insert date 1 year ago from today], how many head injuries did [IF INTTYPE=A OR D READ “you”/ IF INTTYPE=P READ “your child”] experience that you did not see a doctor about?

ENTER COUNT: ______[0-96]

97. DON’T KNOW

99. REFUSED

PROGRAMMER: CREATE INJNUM= INJN + INJN2 IF INJN < 97 AND INJN2 <97. if injn and injn2 are both dk/refused, create sysinjn=1. Set sysinjn=injnum so that respondents move thru the survey as if they have had one injury

if inj and inj2=2 (no injuries) skip to PNCLOSE

ASK if inttype=a, p or d and injn and injn2 =1-96. So we only confirm the number if we have a number.

/if INJNUM=1 then *textsub=injury/lesión; if injnum>1 then *textsub=injuries/lesiones /

INJNTOT. So to confirm, [IF INTTYPE=A OR D READ “you have”/ IF INTTYPE=P READ “your child has”] had [INSERT INJNUM] IF INJNUM>1 READ “separate”] head *textsub* in the past 12 months?

01. YES

02. NO (REASK AND CORRECT)

97. DON’T KNOW

99. REFUSED

//Ask all//

PNCLOSE. That was my last question. Thank you very much for participating in this important research study.

01 CONTINUE

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