Screening Form_In-person Veterans Focus Group_COVER Commission

OMB Control Number: 2900-____

Estimated Burden: 10 minutes

Expiration Date: 06/30/2022

COVER COMMISSION

Veterans In-Person Focus Group

Screening Participation Form

Thank you for calling to find out about the possibility of participating in the Focus Group for Veterans. My name is ___________, and I am with the COVER Commission Support Team.

We would like to hear about your experiences with services/treatments of any mental health concerns—such as PTSD, depression, substance use disorder including opioid use – you are receiving or have received in the past at VA or outside the VA. You will also be asked about your preferences regarding mental health treatment options, challenges related to seeking mental healthcare, and any suggestions for improvement of services. To determine if you qualify, I need to ask you some questions. Is this okay with you?

Before we get started, I must notify you that this information is being collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. The OMB control number is 2900-____.  We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it has a valid OMB number. We anticipate that the time needed to complete this call will average 10 minutes. Information gathered will be kept private to the extent provided by law.

1. [DO NOT ASK] Interviewer Record Gender

☐ Male

☐ Female

☐ Cannot determine based on voice and/or given name

2. First, we would like to confirm that you are a Veteran of the U.S. Military. Have you served in the U.S. Military?

☐ Yes

☐ No – Thank you for your time, but we are only seeking to speak to U.S. Veterans at this time. [END CALL]

3. Do you live in or near (within 40 miles) of the (city/town) area?

☐Yes – Do you have reliable transportation to get to the Focus Group?

• IF NO, thank you for your time. [END CALL]

☐ No – Thank you for your time. [END CALL]

4. For this Focus Group, we are bringing together a group of Veterans so we can find out more about your preferences regarding mental health treatment options, challenges related to seeking mental healthcare, and any suggestions for improvement of services. Have you utilized any mental health services over the past 12 months?

☐ Yes

☐ No – Thank you for your time, but at this time we are only speaking to Veterans that have used mental health services. [END CALL]

5. When did you leave active duty?

☐ Pre 9/11

☐ Post 9/11

The in-person session that we are scheduling is on Date/Time

and will be held at: Location

Are you available on that day and time, and would you be able to fit this into your schedule?

☐Yes

☐No –I’m sorry to hear that. Thank you for your time. [END CALL]

6. You meet the criteria for participation in the Focus Group. If you agree to participate, you will be asked to share your thoughts with a group of about 8 to 10 other Veterans. The Focus Group will be conducted one time and will last two hours. The session will be audio recorded and the information you provide may be used in reports available to the public. If we do use what you say in any way, we will not use your name or provide any names or identifying information of the Veterans who participated in the Focus Group. Your participation in the Group will be completely voluntary and you will be free to leave at any time. Are you still interested in participating?

☐ Yes

☐ No – Thank you for your time. [END CALL]

7. Did you serve in a Combat Theater?

☐ Yes [PLEASE SPECIFY WHERE] _____________________________________

☐ No

8. I’m glad to hear you can make it. In order to send you some information about the Group and provide you with a reminder call/email, I need some contact information. Would you please provide me with your:

Name:

Address:

Best Phone Number to Reach You At:

Email address (if you have one):

[INTERVIEWER PLEASE READ BACK ALL OF THE CONTACT INFORMATION AND MAKE SURE IT IS CORRECT.]

9. Thank you. We will be sending you an email confirmation stating that you have been selected and will be attending the Focus Group, as well as directions and answers to some questions that people often have about Focus Groups. We will also be sending you a background information letter describing the purpose of the Focus Group and what to expect. Please review this information before you attend the Focus Group.

Just to confirm, I have you attending the following Focus Group discussion:

On [Date] at [Time] that will be held at [ADDRESS].

In order for the Group to begin on time, please make sure you arrive to your planned session no later than 15 minutes prior to the scheduled time. We will begin the discussion right at [INSERT TIME]. We are counting on you to participate, so please call us if something comes up and you can no longer attend. Also, please feel free to call us if you have any questions.

Again, my name is (YOUR NAME) and if your schedule changes or if you have any questions you can call [PHONE NUMBER]. We will call to remind you about the Focus Group one to two days before it takes place.

Do you have any questions? [IF NO: Thank you very much for your time, we look forward to seeing you soon.]

☐ Yes – [Answer any other questions]

☐ No – Again, thank you very much for your time; we look forward to seeing you soon. [END CALL]

Suggestions to decrease the burden for this call and other questions or comments can be sent to [email protected].

Veteran Focus Group Screener Page 4 of 4