0920-1050 Participant Screening Form

Attachment 2: Participant screening form

OMB Control No. 0920-1050

Exp. Date 05/31/2022

Public reporting burden of this collection of information is estimated to average 5 minutes per respondent. 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 (0920-1050).

Thank you for your interest in participating in these focus groups. First, we need to know a few things about you. The information you provide in this form will be kept confidential – only project staff will have access to it, we will store it in a database on a secure server with password protection, and we will destroy all data after focus groups are finished and the study is over.

In order to protect your confidentiality, please do not give us your full name. Instead, please choose a nickname that we can use.

Nickname: __________________________________________________________________

Prefer to be contacted via phone or email? _____ Phone _____ Email

Based on your preferred contact method, please give EITHER your phone number OR email:

Phone number: ______________________________________________________________

Email: _____________________________________________________________________

Are you able to attend a focus group discussion on (date, time) at (location):

____ Yes ____ No

Will you need childcare services during this focus group discussion? ____ Yes ____ No

Can you speak and understand conversations in English? ____Yes ____ No

Please answer the following questions about yourself:

Please tell us which race/ethnicity you feel best describes you:

____ White ____ Black or African American ____ Hispanic or Latino ____ Asian

____ American Indian or Alaska Native ____ Native Hawaiian or Other Pacific Islander

Please check here if respondent prefers not to answer: ____ (for interviewer only)

What sex were you assigned at birth?

_____ Male _____ Female

Please check here if respondent prefers not to answer: ____ (for interviewer only)

What is your age: ______ years

How many children do you have? _____

Of these children, how many are boys? _____

What are the ages of your sons? (Check all that apply)

_____ 0-4 years _____ 5-9 years _____ 10-14 years _____ 15-19 years

_____ Over 19 years of age

Of these children, how many are girls? _____

What are the ages of your daughters? (Check all that apply)

_____ 0-4 years _____ 5-9 years _____ 10-14 years _____ 15-19 years

_____ Over 19 years of age

Are you married or do you live with a romantic partner? _____ Yes _____ No

If no, have you ever been married or lived with a romantic partner? _____ Yes _____ No

What is the highest degree or level of school you have completed? (If you’re currently enrolled in school, please indicate the highest degree you have received.)

_____ Less than high school diploma _____ High school degree or equivalent (e.g. GED)

_____ Some college, no degree _____ Associate or Bachelor’s degree

_____ More than a Bachelor’s degree (e.g. Master’s or Doctoral degree)

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