MCH Survey Eligibility and Consent Script_No Inc_ENGLISH

MCH Jurisdictional Survey Eligibility and Consent Scripts

Eligibility

Hello, my name is _________. I am part of a research study that is being done to better understand mother’s and children’s health in [American Samoa/Federated States of Micronesia/Marshall Islands/Northern Mariana Islands/Palau]. Your participation in this study would involve answering a series of questions about your and your children’s health.

[If respondent is Female go to 1, if respondent is Male or you are unsure, go to question 4]

1. Your house has been chosen randomly. Can I ask you a few questions to see if you are eligible to participate in this study?

Yes [Go to 2]
No [Thank individual for their time and leave]

Refused to Answer [Thank individual for their time and leave]

2. Are you 18 years of age or older?

Yes [Go to 3]
No [Go to 4]

Refused to Answer [Thank individual for their time and leave]

3. Are you the mother or female guardian/caregiver of a child 0 to 17 years old living in your household?

Yes [Go to informed consent]
No [Go to 4]

Refused to Answer [Thank individual for their time and leave]

4. Is there a woman in your household 18 years of age or older who is the mother or female guardian/caregiver of a child 0 to 17 years old that I could to talk to?

Yes [Go to beginning]

Yes but she is unavailable [Go to 5]
No [Thank individual for their time and leave]

Refused to Answer [Thank individual for their time and leave]

5. Is there a better time to come back and speak with her?

Yes [Write down time]

No [Thank individual for their time and leave]

Refused to Answer [Thank individual for their time and leave]

Consent

[INFORMED CONSENT OBTAINED AFTER DETERMINING ELIGIBLE CHILD(REN) IN THE HOUSEHOLD]

As I said, we are conducting a survey in [American Samoa/Federated States of Micronesia/Marshall Islands/Northern Mariana Islands/Palau] to learn more about mother’s and children’s health. This survey is part of the Title V MCH Block Grant program, funded by the Health Resources and Services Administration (HRSA).

Your responses will help local Maternal and Child Health programs better understand the health of mothers and children in your area and will be used to help develop and deliver services to families. The survey should take about 50 minutes and the questions will be about your health and your child’s health.

You don’t have to be in this study. You can agree to be in the study now and change your mind later. You do not have to answer any questions you do not want to answer.

Some questions might make you feel uncomfortable, but aside from those possible feelings, there are no known risks to you or your family if you choose to participate.

You will not receive a payment for taking part in the interview.

Your responses will remain private. The only people allowed to see your answers will be the people who work on the study and people who make sure we run the study the right way. Your name will not be on the survey with your answers. We will use a number code to track your answers, not your name.

The survey does not ask about child abuse or neglect.  However, if we learn about child abuse or neglect within any household, we are required to report this to the proper authorities.

Please contact X at (XXX) XXX-XXXX or [email protected] with questions, complaints or concerns about this study.  If you have any questions or concerns about your rights as a research participant, please contact the NORC Institutional Review Board Manager by toll-free phone number at (XXX) XXX-XXXX. 

I will leave this paper with you so you have a record of what I just said. [Provide the paper copy of the informed consent language]

1. Do you have any questions?

Yes [Answer questions, then go to B]
No [Go to B]

Refused to Answer [Thank individual for their time and leave]

2. Do you agree to answer the survey questions?

Yes [Thank individual and begin the questionnaire]
No [Thank individual for their time and leave]

Refused to Answer [Thank individual for their time and leave]