Screener Example

DRAFT

Attachment 6: Example of Screener for Consent to Participate in Cognitive Testing

INTRO

Hello, my name is ______. I am calling on behalf of Westat, a research company in Rockville, Maryland that is conducting survey research for the Centers for Disease Control and Prevention. I am calling to see if you are interested in helping us test questions for an upcoming national survey – we want to ask people if the questions are easy to understand and answer, or if we need to make changes to the questions before the survey actually goes out.

Would you be interested in helping with this project?

No – GO TO THANK AND TERMINATE (“Thank you anyway for your time today, and have a great day.”)

Yes – Great, thank you. Now I just need to make sure that you meet the requirements of the study, so I need to ask you some questions.

Q1. Our first round of interviews will be taking place at Westat’s headquarters, located off of Route 28 -- on Research Boulevard in Rockville, Maryland. Are you within driving or commuting distance of our location?

PROVIDE MORE INFO IF NEEDED: 1600 RESEARCH; NEAR THE CORNER OF RESEARCH AND GUDE DRIVE; 63 OR 54 BUS STOPS IN FRONT OF 1600; ETC.

1. Yes [GO TO Q2]

2. No, not within driving distance of Westat  We will be conducting Phase 2 of this study by telephone in several weeks. Would you be available for a telephone interview during [FILLWITH EXPECTED TIMEFRAME FOR PHONE INTERVIEWS]?

   1. Yes  Okay, I just have a few questions to see if you are eligible for the study. [GO TO Q2]

   2. No  THANK AND TERMINATE (Thank you for taking the time to talk with me today. You are not eligible for this study. Have a great (day/evening)).

Q2. ASK ONLY IF NOT OBVIOUS: Are you male or female?

1. Male

2. Female

INTERVIEWER: WE WANT TO RECRUIT A MIX

Q3. Which of the following age categories are you in?

1. Under 18 – TERMINATE AND THANK (“Based on the requirements of this study, it looks like we can’t include you at this time.”)

2. 18 – 29

3. 30 – 39

4. 40 – 49

5. 50 – 59

6. 60 – 64

7. 65 or over

INTERVIEWER: WE WANT TO RECRUIT A MIX OF AGES.

Q4. Are you of Hispanic or Latino Origin?

a. Yes

b. No

INTERVIEWER: RECRUIT A MIX.

Q5. Are you…READ OPTIONS ALOUD

1. White

2. Black or African American

3. Asian/Pacific Islander

4. American Indian or Alaskan Native

5. Other? ______________________

INTERVIEWER: RECRUIT A MIX OF RACES.

Q6. What is the highest level of education you have completed?

1. 11^th grade or less

2. 12 years of school, no diploma

3. GED or high school graduate (diploma)

4. Some college or technical school

5. College or technical school graduate

6. Post-graduate

INTERVIEWER: RECRUIT A MIX.

Q7. Which of the following best describes you?

Read aloud:

1. Gay or Lesbian

2. Straight

3. Bisexual

Do not read aloud:

4. Uncertain (RECORD WHAT THE PERSON SAYS: _______________________)

Q7a. Is there a different term that you prefer to use – other than [FILL WITH RESPONSE TO 7] to describe yourself?  [RECORD WHAT THE PERSON SAYS, VERBATIM IF AT ALL POSSIBLE]:

___________________________

INTERVIEWER: RECRUIT A MIX WITH A HIGHER CONCENTRATION OF NON-STRAIGHT

Q8. Do you consider yourself to be transgender?

1. Yes

2. no

INTERVIEWER: RECRUIT A MIX

Note - if the potential participant respondent asks about the definition of transgender:

Some people describe themselves as transgender when they experience a different gender identity from their sex at birth. For example, a person born into a male body, but who feels female or lives as a woman would be transgendered. Some transgender people change their physical appearance so that it matches their internal gender identity. Some transgender people take hormones and some have surgery. A transgender person may be of any sexual orientation – straight, gay, lesbian, or bisexual.

If the respondent asks about the definition of gender non-conforming: Some people think of themselves as gender non-conforming when they do not identify only as a man or only as a woman.

THANK AND TERMINATE

Thank you for taking the time to talk with me today. You are not eligible for this study. Have a great (day/evening).

END

[IF ELIGIBLE] You may be are eligible to help with this research project. We will call you back to schedule a specific time. You will receive a [$50 cash upon completion of the in-person interview at Westat / $30 check upon completion of the telephone interview]. Are you interested in participating?

YES — Thank you so much for your willingness to help us. [IF PERSON MEETS TARGET CRITERIA, SCHEDULE FOR A TIME SLOT AS SOON AS POSSIBLE.]

[VERIFY THAT PHONE NUMBER IS BEST ONE TO REACH R, AND GET A BACKUP NUMBER IN CASE OF NEED TO REMIND R OF APPOINTMENT TIME. ALSO GET EMAIL ADDRESS.]

No — Thank you for taking the time to talk with me today and have a great (day/evening).

[VERIFY THAT PHONE NUMBER IS BEST ONE TO REACH R, AND GET A BACKUP NUMBER IN CASE OF NEED TO REMIND R OF APPOINTMENT TIME.]

No — Thank you for taking the time to talk with me today and have a great (day/evening).

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