Form 0920-0572 Focus Group Screening Form

Att. 2: Focus Group Screening Form 

Thank you for your interest in participating in these focus groups. First, we need to know a few things about you. The information you provide in this form will be kept confidential – only staff at Banyan Communications who are involved in this project will have access to it. We will store it in a database on a secure server with password protection, and we will destroy all data after focus groups are finished and the study is over. 

In order to protect your confidentiality, please do not give us your full name. Instead, please choose a nickname that we can use. 

 

Nickname: __________________________________________________________________

  

Please provide your email: _____________________________________________________

 

Are you able to attend a focus group discussion on (date, time) via Zoom:

 

____ Yes         ____ No

  

Can you speak and understand conversations in English?     ____Yes         ____ No

Can you speak and understand conversations in Spanish?     ____Yes         ____ No

 

Please answer the following questions about yourself: 

 

Please tell us which race/ethnicity you feel best describes you: 

____White                ____ African American/Black                 ____ Latino/Latina/Hispanic

____ Asian                ____ American Indian/Alaska Native           ____ Native Hawaiian/Pacific Islander ____ Prefer not to answer

  

How do you describe your gender identity?

____Male                ____Female            ____Male‐to‐female transgender (MTF)   ____Female‐to‐male transgender (FTM)                       ____Other gender identity (specify) 

____ Prefer not to answer

 

What is your age:

 ______ years          ____ Prefer not to answer

 

What is the highest degree or level of school you have completed? (If you’re currently enrolled in school, please indicate the highest degree you have received.)

_____ Less than high school diploma        _____ High school degree or equivalent (e.g., GED)

_____ Some college, no degree                  _____ Associate or Bachelor’s degree

_____ More than a Bachelor’s degree (e.g. Master’s or Doctoral degree)

 

How many children do you have, live with, and/or raise?     

____  0                       ____1           ___2 or more 

 

What are the ages of the children you have, live with, and/or raise? (Check all that apply) 

_____ 0-4 years          _____ 5-12 years          _____ 13 years or older   

 

Please indicate the state that you live in:

A dropdown box will be added with the 50 U.S. states 

 

How would you describe the community that you live in: 

_____Urban            _____Suburban             _____Rural 

 

Do you participate in any of the following outdoor activities? (Select all that apply)

_____Hiking           _____Camping       _____Gardening     _____Golfing          _____Hunting         _____Fishing

 

How often do you participate in outdoor activities such as hiking, camping, visiting parks, or gardening? 

_____Weekly          _____Monthly        _____A few times a year    ____Almost never

 

Does your job require work outdoors such as farming, landscaping, or forest managing, utility work?

_____Yes                _____No        

 

Do you have a dog as a pet? 

______Yes              ____No          

 

Are you aware of any tick-borne diseases* in your area, such as Lyme disease? *Tick-borne diseases are diseases that are spread by tick bites. Tickborne diseases will also include alpha gal syndrome (red meat allergy) which may be triggered by the bite of certain ticks. 

_____Yes                _____No        

 

Are you aware of any mosquito-borne diseases* in your area, such as West Nile Virus? *Mosquito-borne diseases are diseases that are spread by mosquito bites. 

_____Yes                _____No        

 

A person can protect themselves from tick- and mosquito-borne diseases by doing things such as wearing insect repellent, wearing long clothes when in wooded areas, showering soon after being outdoors, emptying items that have filled with water, or treating clothes with permethrin. Do you do any of these things? 

_____Yes                _____No        

 

(If yes then) How often do you do these activities?

_____Always          _____Often             _____Sometimes    _____Rarely