Web-based Recruitment Screener

Attachment H: Web-based Recruitment Screener

Thank you for your interest in an upcoming study that Westat is conducting.

Westat is helping the Centers for Disease Control and Prevention (CDC) to develop a national survey about health and injuries that asks questions about physical injuries, harassing behaviors, and unwanted sexual activity. You do not need to have experienced any of these issues to be eligible for the interview.

We want to be sure that the survey questions make sense to different kinds of people. So we are trying to find people who are interested in helping us by giving their reactions to the questions. If you are interested and eligible, we will invite you to an in-person interview, which will take about an hour. At the end of the interview you will receive $40 cash.

To see if you are eligible for the study, please click on the continue button below.

1. What is your gender?

• FEMALE

• MALE

• OTHER

2. How old are you?

________

REF

DK

IF UNDER 18, REF OR DK, RESPONDENT IS INELIGIBLE. THANK AND END

3. When was the last time you participated in a research interview or focus group?

• LESS THAN 6 MONTHS AGO

• 6 MONTHS AGO OR MORE

• NEVER

IF LESS THAN 6 MONTHS AGO, REF OR DK, INELIGIBLE. THANK AND END.

Next are some questions about things that you may or may not have experienced. We are looking for people with a mix of different experiences, so your honest responses are appreciated.

4. At any point in your life, have you ever been verbally harassed in a sexual way or had someone say unwanted or offensive sexual things to you?

• YES

• NO

4a. (IF YES IN #4) Has this happened to you at any time in the past 12 months?

• YES

• NO

5. At any point in your life, has anyone ever harassed you in a way that made you feel uncomfortable, anxious, or afraid? For example, has someone repeatedly watched, followed, or spied on you, made unwanted and excessive attempts to contact you, or monitored your activities or location using devices or software on your phone or computer?

• YES

• NO

5a. (IF YES IN #5) Has this happened to you at any time in the past 12 months?

• YES

• NO

6. At any point in your life, have you ever had any experienced unwanted kissing or groping?

• YES

• NO

6a. (IF YES IN #6) Has this happened to you at any time in the past 12 months?

• YES

• NO

7. At any point in your life, have you ever had sex when you did not want it to happen?

• YES

• NO

7a. (IF YES IN #7) Has this happened to you at any time in the past 12 months?

• YES

• NO

8. At any point in your life, have you ever experienced physical violence by a spouse or romantic partner, or has a spouse or partner ever tried or threatened to do this?

• YES

• NO

8a. (IF YES IN #8) Has this happened to you at any time in the past 12 months?

• YES

• NO

Next are some questions about your background.

9. What is the highest grade or level of education you have completed?

• LESS THAN HIGH SCHOOL

• HIGH SCHOOL DIPLOMA/GED

• SOME COLLEGE (INCLUDES ASSOCIATE’S)

• COLLEGE GRADUATE (BA, BS)

• GRADUATE/PROFESSIONAL DEGREE (MA, MS, MD, JD, PhD, etc.)

• REF

• DK

10. Are you of Hispanic, Latino, or Spanish origin?

• YES

• NO

• REF

• DK

11. What is your race and origin?

MARK ALL THAT APPLY.

• WHITE

• BLACK OR AFRICAN AMERICAN

• AMERICAN INDIAN/ALASKAN NATIVE

• ASIAN

• NATIVE HAWAIIAN AND OTHER PACIFIC ISLANDER

• OTHER ______________________

• REF

• DK

12. Do you regularly use any of the following devices at home?

• A cell phone that is a smartphone (IF YES, What brand is it? _____________________)

• A cell phone that is not a smartphone

• A tablet device (IF YES, What brand is it? _____________________________)

The one-hour interview will take place during the week of (DATE) at (LOCATION) and we will provide you with $40 to help offset your travel costs and to thank you for your time. During the interview, you will be asked to give your feedback on survey questions.

13. If you are eligible, would you be interested in participating in the interview?

• YES - CONTINUE

• NO - THANK AND END.

14. Please provide your name and contact information so we can reach out to you if you are eligible for the interview. If you prefer, you can just provide your initials or some way to refer to you if we reach out to you.

Name ______________________________________________________________________

Address ____________________________________________________________________

Phone Number _______________________________________________________________

Email Address________________________________________________________________

13. We would like to record the interview(s). This allows us to carefully review the discussion and ensure that we accurately capture your thoughts and opinions. Will that be alright with you?

• YES

• NO

Thank you. If you are eligible, we will be in touch with you to schedule a time for the interview.

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