Script for Initial Verbal Screening

Form Approved

OMB No. 0920-0888

Exp. Date xx/xx/20xx

Attachment 3: Script for Initial Verbal Screening

(Potential subjects with influenza-like illness will be referred to the study recruiter by the staff at the health care clinic.)

Hi, my name is __________ and I work for the National Institute for Occupational Safety and Health. We are conducting a study of people with influenza. The study takes about an hour and a half, and you will receive a $40 gift card for participating. Your participation is completely voluntary. Would you like to hear more about it?

(If the person says they are not interested, thank them for their time. If they are interested, continue with the script.)

For the study, you will be asked to fill out a short questionnaire about your health. Your oral temperature will be taken, and two nasal swabs will be collected from you. Next, you will be asked to don a mask and breathe and cough normally for 40 minutes. While you are doing this, a collection system will collect the cloud of airborne particles that you produce. Finally, 5 ml of blood will be collected from you. Are you interested in participating?

(If person says they are not interested, thank them for their time. If they are interested, continue with the script.)

I need to ask you a few questions to see if you are eligible to participate in the study. First, are you 18 or older?

(If the person says yes, continue with the questions. If they say no, explain that they are not eligible and thank them for their interest.)

(If the person is female) Are you pregnant?

(If the person says no, continue. If they say yes, explain that they are not eligible and thank them for their interest.)

How long have you been sick?

Public reporting burden of this collection of information is estimated to average 3 minutes 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0888).

(If the person says they have been sick (symptomatic) for 3 days or less, continue with the questions. If they have been sick for more than 3 days, explain that they are not eligible and thank them for their interest.)

For the study, you will need to wear a mask for 40 minutes. Do you have any medical conditions or illnesses that would make this difficult or uncomfortable for you? Some examples would be severe asthma, COPD, tuberculosis, diabetes, or heart disease.

(If the person says no, continue. If they say yes, explain that they are not eligible and thank them for their interest.)

We will need to draw 5 ml of blood from your arm for the study. Is that OK with you?

(If the person says yes, continue. If they say no, explain that they are not eligible and thank them for their interest.)

OK, great. You are eligible to participate in the study if you would like to do so. Do you have any questions for me?

(Answer any questions the person may have.)

Would you like to participate in the study?

(If the person says yes, give them the consent form and ask them to read and sign it. If they say no, thank them for their time.)