Form 1 Consumer Recruitment Screener

OMB Control #0925-0769

Expiration Date 12/31/2021

Public reporting burden for this collection of information is estimated to average 5 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 current 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 NIH, Project clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0769). Do not return the completed form to this address.

Federal COVID-19 Response

Audience Feedback Teams for Quick and Ongoing Message, Materials, and Usability Testing – Consumer Recruitment Screener

DEMOGRAPHIC BREAKDOWN FOR EACH OF THE FEEDBACK TEAMS

Each audience feedback team will reflect a mix of

genders, ages, geographic region, and COVID-19 diagnoses, as possible.

3 Target Audiences	Audience 1	Audience 2	Audience 3
	All ethnicities (excluding African American/Black and Hispanic Latino) affected by COVID-19	Bilingual Hispanics/Latinos affected by COVID-19	Blacks/African Americans affected by COVID-19
Participant Quantities Per Target Audience	Recruit 20 feedback team members	Recruit 20 feedback team members	Recruit 20 feedback team members
Commitment	Up to 8 60-minute sessions	Up to 8 60-minute sessions	Up to 8 60-minute sessions

QUOTAS AND ELIGIBILITY

• Recruit 60 total participants: 20 per target audience. Target audiences include individuals who have been affected by COVID-19 in some capacity. Groups will be dived by self-report of race and ethnicity: (1) bilingual Hispanic and Latinos, (2) Blacks/African Americans, and (3) individuals reporting any other racial or ethnic identity (exclusive of Black/African American or Hispanic/Latino).

• Recruit a mix of gender, age, state, geographic region, prior COVID-19 diagnosis, and close family member COVID-19 diagnosis (past or present), as possible.

RECRUITMENT SCREENER

Month, 2021

Introduction

Hello, my name is _______________ and I’m calling from _________________about an upcoming research project sponsored by the U.S. Federal COVID-19 Response Team.

We want to talk with men and women who are concerned about treatment options for COVID-19; who have been diagnosed with COVID-19 now or in the past; or who have a friend or family member who has been diagnosed with COVID-19, about how we can better reach people with an important resource for information about available COVID-19 treatment clinical trials and treatment options.

We are interested in recruiting participants who are willing to participate in up to six qualitative virtual feedback sessions (online bulletin boards, focus groups, in-depth interviews, website usability testing activities [i.e., card sorts]) over a 12-month period. Each feedback session will take place virtually via Zoom, and last, on average, 60 minutes.

To maintain participants’ privacy, we will use first names only during the sessions and your name will not be used in any project materials. To thank you for your time, you will be given a monetary token of appreciation following each activity that you participate in. To see if you qualify to participate, we need to ask you a few questions. These questions will take less than 6 minutes.

Eligibility Questions

RECRUIT 20 TOTAL PARTICIPANTS PER FEEDBACK TEAM (60 TOTAL PARTICIPANTS).

• RECRUITER TO CONFIRM THE FOLLOWING: TARGET AUDIENCE 1 & 3 MUST SPEAK ENGLISH CLEARLY.

• TARGET AUDIENCE 2 MUST BE BILINGUAL. VENDOR TO CONFIRM.

1. What is your gender?

( ) Male

( ) Female

( ) Prefer to describe _______

RECRUIT A MIX OF GENDERS, AS POSSIBLE.

2. How old are you? ______

RECRUIT A MIX OF AGES AS POSSIBLE.

If under 18 years of age, THANK AND DISMISS.

3. In which state do you live? _____________

RECRUIT A MIX OF STATES.

4. Which of the following best describes the type of area you live in?

( ) Urban (city)

( ) Suburban

( ) Rural

( ) Small city or town

( ) Reservation or Frontier (classify as rural)

RECRUIT A MIX OF GEOGRAPHIC REGIONS AS POSSIBLE.

5. What is the closest major city to where you live?

Record:_________

RECRUIT A MIX OF DESIGNATED MARKET AREAS AS POSSIBLE.

6. Which of the following best describes your highest level of education?

(     ) No formal schooling

(     ) Less than high school/some high school, no diploma

(     ) High school graduate or GED

(     ) Some college or technical school

(     ) 4-year college degree

(     ) Post-graduate studies or advanced degree (master’s or higher)

RECRUIT LOWER EDUCATION AS POSSIBLE.

7. Are you Hispanic, Latino/a, or Spanish Origin?

(     ) No, not of Hispanic, Latino/a, or Spanish origin DISMISS FOR TARGET AUDIENCE 2.

(     ) Yes, Mexican, Mexican American, Chicano/a

(     ) Yes, Puerto Rican

(     ) Yes, Cuban

(     ) Yes, Another Hispanic, Latino/a or Spanish origin

8. What is your race? (One or more categories may be selected)

(    ) American Indian or Alaska Native

(     ) Asian

(     ) Black or African American MUST BE CHECKED FOR TARGET AUDIENCE 1. CANNOT

(     ) Native Hawaiian or Other Pacific Islander BE CHECKED FOR TARGET AUDIENCE 3.

(     ) White

9. Do you work in any of the following fields?

(     ) Public Health THANK AND DISMISS

(     ) Marketing THANK AND DISMISS

(     ) Public Relations THANK AND DISMISS

(     ) Healthcare THANK AND DISMISS

(    ) None of the above

10. What type of health insurance do you have, if any?

(     ) A plan through your employer/work or your spouse’s employer/work (private insurance)

( ) Medicare

(     ) Medicaid [note to recruiter if applicable: MediCal is California’s Medicaid program]

( ) Military health care

( ) VA coverage

( ) Some other government program

( ) A plan I purchased myself (such as through a healthcare market place)

( ) Uninsured/I do not have health insurance

( ) Other. Please specify: ____________

11. Where do you usually receive your medical care?

(     ) A doctor’s office

(     ) A clinic or health center (including a “Federally Qualified Health Center” [FQHC])

( ) A health department

(     ) A hospital emergency room

( ) A hospital outpatient department

(     ) A Veterans Administration (VA) clinic

(     ) A holistic or alternative medicine provider

( ) Other. Please specify: ____________

RECRUIT A MIX OF STATES AS POSSIBLE.

12. Is your health care provider respectful of you and your culture?

(     ) Always

(     ) Almost always

(     ) Sometimes

(     ) Almost never

(     ) Never

RECRUIT A MIX AS POSSIBLE.

13. Have you ever tested positive for COVID-19?

(     ) Yes

(     ) No

• If YES TO #11, have you ever received COVID-19 treatments?

• Yes

• No

• If YES TO #11 ALSO ASK, have you ever participated in a clinical trial related to COVID-19?

• Yes

• No

RECRUIT A MIX AS POSSIBLE.

14. Has a member of your family or close friend ever tested positive for COVID-19?

(     )Yes

(     )No

• IF YES TO #12: Are they currently in the hospital?

• Yes

• No

• IF ALSO YES TO #12: Have they ever received COVID-19 treatments?

• Yes

• No

• IF ALSO YES TO #12: Have they ever participated in a clinical trial related to COVID-19?

• Yes

• No

RECRUIT A MIX AS POSSIBLE.

[Suggested language when terminating a call:
“Thank you very much for your time today. We are looking to recruit a wide variety of participants to participate on these feedback teams. Unfortunately, we have filled participant slots with your background. However, we thank you for your interest in this project.”

INVITATION

Thank you for answering my questions. We would like to invite you to participate on an audience feedback team.

Are you interested and able to participate?

( ) Yes;

( ) No; THANK AND DISMISS

Do you have access to an internet-connected computer with audio and video (other than a smart phone)? We are asking this question because sometimes we will be showing participants materials through a shared screen and participants will need a large enough screen to view the materials in their entirety and in detail.

(     )Yes

( ) Not sure THANK AND DISMISS.

(     )No THANK AND DISMISS.

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