0920-1264 Women's Health Need STUDY_ Eligibility Screener

Women’s Health Needs Study: The Health of US-Resident Women from Countries with Prevalent Female Genital Mutilation/Cutting (FGM/C)

Att G1 WHNS Eligibility Screener (English)_revised 060220

Women's Health Needs STUDY_SCREENER

OMB: 0920-1264

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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

Shape5
Other, please specify:



Shape6

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].



Shape7

4. In which country were you born?



Don’t Know

Prefer not to answer

5. In which country was your mother born?

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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:


  1. Burkina Faso

  2. Egypt

  3. Eritrea

  4. Ethiopia

  5. Gambia

  6. Guinea


  1. Mali

  2. Mauritania

  3. Sierra Leone

  4. Somalia

  5. 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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AuthorSabrina Bauroth
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