0920-1264 Women's Health Need STUDY_ Eligibility Screener

Attachment G1: WHNS Revised Screener -- English

Public reporting burden of this collection of information is estimated to average 1 minute 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).

Screener Start Time: ___ Hour ____ Minute

SECTION A. SCREENER

The following questions will ask you general information about the languages you speak, where you were born, and your age. Please answer these questions to tell if you are a good fit for this study.

1. Have you previously participated in the Women’s Health Needs Study (WHNS)?

Yes [END SURVEY]

No

2. Which of the following languages do you speak?

[SELECT ALL THAT APPLY]

Amharic

Arabic

English

Somali

French

Tigrinya

Other, please specify:

3. Which language would you prefer to use for this interview? [INTERVIEWER NOTE: IF YOU DO NOT SPEAK THE LANGUAGE PREFERRED, MAKE NOTE AND END INTERVIEW].

4. In which country were you born?

Don’t Know

Prefer not to answer

5. In which country was your mother born?

Don’t Know

Prefer not to answer

6. How old are you?

Under 18 years [END SURVEY]

18-24

25-29

30-34

35-39

40-49

Over 49 years [END SURVEY]

Prefer not to answer

ELIGIBILITY CHECKLIST

EACH BOX SHOULD BE CHECKED BEFORE MOVING FORWARD WITH SURVEY.

Respondent did not previously participate in WHNS

Respondent between 18-49 years old

Respondent OR respondent's mother born in one of the following countries:

Burkina Faso Egypt Eritrea Ethiopia Gambia Guinea

Mali Mauritania Sierra Leone Somalia Sudan

Interviewer is available to conduct interview in respondent's preferred language (Question 3)

If respondent meets all 4 criteria above, please check the eligible box below.

Respondent is eligible

Respondent is NOT eligible [END SURVEY]

If respondent is eligible, then review consent material and proceed to interview.

Screener End Time: ___Hour

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File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Sabrina Bauroth
File Modified	0000-00-00
File Created	2021-01-14