0920-0800 Attachment C1 Screening Form Example

Appendix C1

Example of a Screening Form

Form Approved

OMB No. 0920-0800

Exp. Date MM/DD/20YY

Example of a Recruitment Screener

Colorectal Cancer Screening

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 informaiton 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0800)

Introduction

Hello, my name is _________. I’m with _______, (insert qualitative research firm description). On behalf of the federal Centers for Disease Control and Prevention, we are planning (insert focus groups or in-depth interviews) about (insert specific cancer type or cancer communication campaign). Some people we speak with today will be invited to participate in the discussion (add as needed: and will receive a token of appreciation of $____, for about 120 minutes of your time. May I ask you a few questions?

Demographic Questions

1. Gender:

__ Male

__ Female

2. Ethnicity:

__ Hispanic or Latino

__ Not Hispanic or Latino

3. Race:(respondents may select more than one response category)

__ White

__ Black or African American

__ American Indian or Alaska Native

__ Asian

__ Native Hawaiian or Other Pacific Islander

4. Which of the following age categories includes you?

__ Under 50 years old

__ 50 to 60 years old

__ 61 to 70 years old

__ 71 to 74 years old

__ 75 or older

Topic-specific Questions

5. Have you or your spouse ever worked for any of the following types of organizations in a paid position?

__ Doctor’s office, hospital, clinic, pharmaceutical or drug company

__ Health department or community health agency

__ Marketing, advertising or public relations agency or department

__ American Cancer Society (ACS) or another cancer organization

6. Do you have any kind of health insurance to pay for routine health care?

__ Yes

If yes: Which plan or plans? _______________________________

__ No

__ Don’t know

7. Have you ever been told by a doctor that you have [READ SLOWLY] any sort of bowel disease such as colitis, inflammatory bowel disease, Crohn’s disease, colon cancer, or polyps. POLYPS ARE SMALL GROWTHS IN YOUR COLON OR RECTUM.

__ Yes (Which one/s: ________________)

__ No

__ Not sure/don’t know

8. Have you, your mother, father, brother, sister, or child ever had colon cancer?

__ Yes

__ No

__ Not sure/don’t know

9. Have you ever been diagnosed with any kind of cancer?

__ No

__ Not sure/don’t know

__ Yes

If yes, ask: What kind of cancer? _________________.

For “skin cancer” only, skip to Q14. For other cancers, ask:

When were you diagnosed? _______________________

10. When, if ever, was the last time you participated in a focus group?

__ Have never participated

__ Within the last 6 months: What was the topic? ______________________

__ More than 6 months ago

11. When was your last routine check-up or physical? ______________ [Information only]

12. Thinking about the doctor visits you have had over the last 5 years, have you been tested for:

a. Diabetes or “Sugar”

__ Yes

__ No [Information Only]

b. Heart problems

__ Yes

__ No [Information Only]

c. [Ask Females only] Breast cancer

__ Yes

__ No [Information Only]

d. [Ask Males only] Prostate cancer

__ Yes

__ No [Information Only]

e. Colon cancer

__ Yes

__ No

__ Don’t know

Now I am going to ask you some questions to determine if you have had some particular medical tests. I am used to talking with people about these tests, and I hope that you will not feel awkward about my questions.

12a. Have you ever been given a test kit to check for blood in your stool? This is a kit which you could use at home to collect a few stool samples from the toilet, and put them on a card?

__ No

__ Yes

__ Don’t know

If respondent answered ‘yes’, then ask:

Did you complete the test and return the card to the lab or doctor?

__ No

__ Don’t remember

__ Yes

If respondent answered ‘yes’, then ask:

When was the last time you completed this test?

[Record answer____________________]

If respondent doesn’t remember, try to jog memory by asking: Approximately when?

__ Within the last year

__ Within the last 2 years

__ More than 2 years ago

12b. Have you ever had a test for which a doctor inserted a tube in your rectum or colon?

__ No

__ Yes

__ Don’t know

If the respondent answered ‘yes’, then ask:

Do you remember anything about the name of the test or tests? It’s OK if you’re not sure or don’t know the exact pronunciation. Anything you remember about the tests or the names will help me.

Record anything respondent says: _____________________________________

[OK if they say they don’t know the name(s)]

[Read regardless of what respondent says] Sigmoidoscopy (SIG-MOYD-OSS-CO-PEE) is one common test. The other test is called a colonoscopy (CO-LON-OSS-CO-PEE).

Both of these tests involve a lighted tube that the doctor inserts into your rectum to view the colon. The sigmoidoscopy is often done in the doctor’s office without medication and is relatively simple. The colonoscopy uses a longer tube and typically you are given medication to relax and you must be driven home by someone else. Some people confuse these tests with one in which a tube is inserted through the mouth or the nose. That’s a different test.

Now that I have explained more about these tests, do you recall whether you have ever had a colonoscopy? That is the test that uses a longer tube and typically involves some medication. Afterwards, someone else must drive you home.

__ No

__ Yes [Continue to ask when colonoscopy was done]

__ Don’t know

If respondent answered ‘yes’, then ask:

Approximately, when was the last time you had a colonoscopy?

[Record answer: ________________________]

If respondent doesn’t remember, try to jog memory by asking:

Approximately when?

__ Within the last 2 years

__ Within the last 5 years

__ 5 or more years ago, but less than 10 years

__ Longer than 10 years ago

12c. Do you recall whether you have ever had a sigmoidoscopy? The test is usually done

without medication in the doctor’s office.

__ No

__ Yes

__ Don’t know

If respondent answered ‘yes’, then ask:

Approximately, when was the last time you had a sigmoidoscopy?

[Record answer: ________________________]

If respondent doesn’t remember, try to jog memory by asking:

Approximately when?

__ Within the last 2 years

__ Within the last 5 years

__ 5 or more years ago, but less than 10

__ More than 10 years

12d. Have you ever had an x-ray test of your colon, for which you first were given an enema through your rectum and then x-rays of your colon were taken? This usually is called a barium enema, or lower GI test. [Note: If person volunteers that he/she has had a tube down his/her throat or swallowed “chalky stuff,” before an x-ray, this is not the same test. OK to continue if test did NOT involve an enema.]

__ No

__ Yes

__ Don’t know

If respondent answered ‘yes’, then ask:

Approximately, when was the last time you completed this test?

[Record answer: ________________________]

If respondent doesn’t remember, try to jog memory by asking:

Approximately when?

__ Within the last 2 years

__ Within the last 5 years

__ 5 or more years ago, but less than 10 years

__ More than 10 years ago

13. What is the last grade or year of school you completed?

__ Less than high school

__ Some high school

__ Completion of high school

__ Some college

__ Completion of college

__ Post-graduate degree

14. Please stop me when I read the range that includes your total annual household income.

__ Less than or equal to $____________

__ More than $_____________; less than or equal to $ ___________

__ More than $; less than or equal to $_____________

__ More than $____________________

Invitation

Thank you for answering my questions. We are convening discussions with the general public to discuss (insert specific cancer communication campaign). I hope you will be interested in participating.

The current options are on (insert day/time) at:

Group 1: ___________PM Eastern Daylight Time --OR--

Group 2: ___________PM Eastern Daylight Time

Are you available?

If YES: Record contact information below.

Name: ___________________________________________________________

Address: _________________________________________________________

City: ________________ State: ______ Zip: ___________________

Day Phone: ____________________________

Evening Phone: ________________________

Email: ________________________________

Other contact information: __________________________________________

If NO, please ask:

Would you like to be contacted again about this study if additional times are scheduled?

_____ Yes; Thank you. We will contact you if we schedule additional groups.

_____No

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