Appendix E_screening questionnaire
In-Home Food Safety Behaviors and Consumer Education: Annual Observational Study
Appendix E_screening questionnaire
OMB: 0583-0169
Appendix E:
Screening
Questionnaires
Appendix E1:
Web-Based Screening Questionnaire
Screen 1
Thank you for your interest in our research study, which is funded by the U.S. Department of Agriculture and conducted by researchers from North Carolina State University and RTI International.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0583-0169 and the expiration date is xx/xx/xxxx. The time required to complete this information collection is estimated to average 8 minutes, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information.
Screen 2
If you are eligible for the study on recipe testing, you will be asked to prepare a meal while being videotaped and to participate in an interview. The study will last up to 2 hours, and you will receive a $75 gift card and a small gift for taking part in the study.
To determine whether you are eligible, you will need to answer a few questions. These questions will take less than 10 minutes to complete. Your participation in this study is completely voluntary. All of your answers and your contact information will be kept private. Please click the “>>” arrows below if you would like to continue.
Have you cooked or worked professionally in a food preparation setting in the past 5 years?
☐ Yes 🡪 Ineligible. Terminate.
☐ No
Have you received any type of food safety training, such as ServSafe, in the past 5 years?
☐ Yes 🡪 Ineligible. Terminate.
☐ No
☐ Yes 🡪 Ineligible. Terminate.
☐ No
Do you have any children living in your household who are less than 18 years of age?
☐ Yes
☐ No
On average, how often do you cook breakfast at home using shell eggs and breakfast meat made from raw pork? (Please do not include breakfast that only includes cereal, grits, oatmeal, yogurt, toast, liquid eggs, or heat and serve breakfast meats that do not require cooking.)
☐ Never 🡪 Ineligible. Terminate.
☐ Less than once per month 🡪 Ineligible. Terminate.
☐ At least once a month
☐ At least twice a month
☐ At least 3 times per month
☐ 4 or more times per month
Which of the following breakfast meats made from raw pork (i.e., not heat and serve) have you cooked during the past 6 months?
☐ Bacon
☐ Breakfast sausage links
☐ Pre-made breakfast sausage patties
☐ Breakfast sausage purchased in a tube or roll used to make your own patties (see photo)
☐ Chorizo
☐ Canadian bacon
☐ None of the above
Must select sausage (links, patties, tube, chorizo) to be eligible. If none of these are selected, Ineligible and Terminate.
Which of the following fruits do you have experience cutting?
☐ Cantaloupe
☐ Watermelon
☐ Honeydew melon
☐ None of the above 🡪 Ineligible. Terminate.
How do you currently describe yourself?
☐ Female
☐ Male
☐ Transgender
☐ None of these
☐ Prefer not to answer
Are you …?
☐ Hispanic or Latino
☐ Not Hispanic or Latino
What is your race? Please select one or more.
☐ American Indian or Alaska Native
☐ Asian
☐ Black or African American
☐ Native Hawaiian or Other Pacific Islander
☐ White
What is your age?
☐ Under 18 🡪 Ineligible. Terminate.
☐ 18 to 34
☐ 35 to 54
☐ 55 to 64
☐ 65 to 75 🡪 Ineligible. Terminate
☐ 76 or older 🡪 Ineligible. Terminate
What is the highest level of education that you have completed?
☐ Less than high school
☐ High school graduate or GED
☐ Technical or vocational school
☐ Some college, but did not get a degree
☐ 2-year associates degree
☐ 4-year college degree
☐ Postgraduate degree
Are you or any members of your household …? (Select all that apply.)
☐ 65 years of age or older
☐ 5 years of age or younger
☐ Pregnant
☐ Breastfeeding
☐ Diagnosed with an allergy to any food or food ingredient
☐ Diagnosed with diabetes or kidney disease
☐ Diagnosed with a condition that weakens the immune system, such as cancer, HIV, or AIDS; a recipient of a transplant; or receiving treatments, such as chemotherapy, radiation, or special drugs or medications to treat these conditions
☐ None of the above
Where did you hear about this study?
☐ Craigslist
☐ Email from a North Carolina extension program
☐ Sign
Specify location: __________________________
☐ Other
Specify location: __________________________
☐ Don’t know
[COVID]
In the last 7 days, have you been in close contact with someone who has been diagnosed as having COVID-19 by a healthcare professional?
☐ Yes🡪 Terminate.
☐ No
Have you been diagnosed with COVID-19 in the past 14 days?
☐ Yes🡪 Terminate.
☐ No
Do you have any (one or more) symptoms of COVID-19 such as cough, fever, shortness of breath, chills, muscle pain, new loss of taste or smell?
☐ Yes🡪 Terminate to Covid Screen
☐ No
Are you willing to follow all COVID-19 safety and sanitation procedures while participating in this study including wearing appropriate personal protective equipment?
☐ Yes
☐ No 🡪 Terminate
Do you have any of the following conditions that may increase your risk of serious illness from COVID-19? (Select all that apply.)
☐ Chronic lung disease or moderate to severe asthma
☐ Heart condition
☐ Immunocompromised. (This can result from cancer treatment, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications)
☐ Body mass index (BMI) of 40 or higher
☐ Diabetes or pre-diabetes
☐ Chronic kidney disease undergoing dialysis
☐ Liver disease
☐ None of the above
Thank you for taking the time to complete this survey to determine your eligibility for this study. We have determined that you are eligible to participate in the study!
Due to the COVID-19 pandemic, there are some additional precautions we must take when you participate in the study. Please be on the lookout for an email from our research team within a few business days regarding how to prepare to come to your study session and what you should expect.
☐ Yes
☐ No 🡪 Terminate.
Contact Screen 1 (if no boxes checked in question 19)
Great! Please enter your name and telephone number so that a study team member can call you and schedule an appointment for the Breakfast Study at a day and time that works best for you and send you text message reminders. The study will last up to 2 hours, and you will receive a $75 gift card and a small gift for taking part in the study. Please note that additional screening for COVID-19 exposure and symptoms will occur upon arrival which may determine you ineligible at that time. If you’d like, you can download a copy of the consent form here for your review; you will also receive a paper copy upon arrival.
[ENTER NAME]
[ENTER TELEPHONE NUMBER]
[Go to Contact Screen 3]
Contact Screen 2 (if ANY boxes checked in question 19)
Great! Please enter your name and telephone number so that a study team member can call you and schedule an appointment for the Breakfast Study at a day and time that works best for you. The study will last up to 2 hours, and you will receive a $75 gift card and a small gift for taking part in the study. Please note that additional screening for COVID-19 exposure and symptoms will occur upon arrival which may determine you ineligible at that time. If you’d like, you can download a copy of the consent form here for your review; you will also receive a paper copy upon arrival.
Please note that you have indicated that because of experiences you may be at risk for developing severe illness should you contract COVID-19. Participation in this research requires in-person interaction which may result in contracting COVID-19. Precautions including physical distancing, wearing PPE and cleaning and disinfection, will be taken to mitigate possible transmission of COVID-19; however, you may want to take additional personal precautions.
Contact Screen 3
Please enter your email address so we can send you a confirmation email with directions. [ENTER EMAIL ADDRESS; REQUIRE DOUBLE ENTRY FOR VERIFICATION].
☐ No Email
[If no email] Please enter your mailing address. [STREET ADDRESS, CITY, NC, ZIP]
Thank you for your time. A study team member will call you in 1 or 2 days to schedule an appointment with you.
If you have any questions about the study or scheduling, you may contact Lisa Shelley at 919-659-8254. If you have concerns about your rights as a research participant, contact North Carolina State University’s Office of Research Protection at 919-515-8754 or via email at [email protected].
Ineligible/Covid Screen
Thank you for your time. Unfortunately, you are not eligible to take part in our study. Please contact your medical provider to discuss your needs. In addition to contacting your medical provider, if you are an NC State University employee, use this form to self-report: Employee Self-Report Form. If you are an NCSU student, please use this form to report: Student Self Report Form. If you are unaffiliated with NC State University, please call your medical provider to report symptoms.
Ineligible/Terminate Screen
Thank you for your time. Unfortunately, you are not eligible to take part in our study. Have a great day.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0583-0169 and the expiration date is XX/XX/XXX. The time required to complete this information collection is estimated to average 8 minutes, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. |
Appendix E2:
Telephone Screening Questionnaire
Hello. My name is _______________. Thank you for your interest in our research study, which is funded by the U.S. Department of Agriculture and conducted by researchers from North Carolina State University and RTI International.
If you are eligible for the study on recipe testing, you will be asked to prepare two recipes while being videotaped and to participate in an interview at a day and time convenient for you. The study will last no more than 2 hours, and you will receive $75 and a small gift for taking part in the study.
To determine whether you are eligible, I need to ask you a few questions. These questions will take less than 10 minutes to complete. Your participation in this study is completely voluntary. All of your answers and your contact information will be kept private.
May I please ask you a few questions to determine whether you are eligible to participate in our study?
☐ Yes
☐ No🡪 Refusal. Terminate.
Have you cooked or worked professionally in a food preparation setting in the past 5 years? (Select one.)
☐ Yes 🡪 Ineligible. Terminate.
☐ No
Have you received any type of food safety training, such as ServSafe, in the past 5 years? (Select one.)
☐ Yes 🡪 Ineligible. Terminate.
☐ No
Have you participated in any research studies about cooking in the past 4 years?
☐ Yes 🡪 Ineligible. Terminate.
☐ No
Do you have any children living in your household who are less than 18 years of age?
☐ Yes
☐ No
On average, how often do you cook breakfast at home using shell eggs and breakfast meat made from raw pork? (Please do not include breakfast that only includes cereal, grits, oatmeal, yogurt, or toast, liquid eggs, or heat and serve breakfast meats that do not require cooking.)
☐ Never 🡪 Ineligible. Terminate.
☐ Less than once per month 🡪 Ineligible. Terminate.
☐ At least once a month
☐ At least twice a month
☐ At least 3 times per month
Which of the following breakfast meats made from raw pork (i.e., not heat and serve) have you cooked during the past 6 months?
☐ Bacon
☐ Breakfast sausage links
☐ Pre-made breakfast sausage patties
☐ Breakfast sausage purchased in tube or roll used to make your own patties
☐ Chorizo
☐ Canadian bacon
☐ None of the above
Must select sausage (links, patties, tube, chorizo) to be eligible. If none of these are selected, Ineligible and Terminate.
Which of the following fruits do you have experience cutting?
☐ Cantaloupe
☐ Watermelon
☐ Honeydew melon
☐ None of the above 🡪 Ineligible. Terminate.
How would you currently describe yourself? (Read list. Select one.)
☐ Female
☐ Male
☐ Transgender
☐ None of these
☐ Prefer not to answer
Are you …? (Select one.)
☐ Hispanic or Latino
☐ Not Hispanic or Latino
What is your race? (Read list. Select one or more)
☐ American Indian or Alaska Native
☐ Asian
☐ Black or African American
☐ Native Hawaiian or Other Pacific Islander
☐ White
What is your age?
☐ Under 18 🡪 Ineligible. Terminate.
☐ 18 to 34
☐ 35 to 54
☐ 55 to 64
☐ 65 to 75 🡪 Ineligible. Terminate
☐ 76 or older 🡪 Ineligible. Terminate
What is the highest level of education that you have completed? (Select one.)
☐ Less than high school
☐ High school graduate or GED
☐ Technical or vocational school
☐ Some college, but did not get a degree
☐ 2-year associate’s degree
☐ 4-year college degree
☐ Postgraduate degree
Are you or any members of your household …? (Read list. Select all that apply.)
☐ 65 years of age or older
☐ 5 years of age or younger
☐ Pregnant
☐ Breastfeeding
☐ Diagnosed with an allergy to any food or food ingredient
☐ Diagnosed with diabetes or kidney disease
☐ Diagnosed with a condition that weakens the immune system, such as cancer, HIV, or AIDS; a recipient of a transplant; or receiving treatments, such as chemotherapy, radiation, or special drugs or medications to treat these conditions
☐ None of the above
Where did you hear about this study? (DO NOT READ. Select all that apply.)
☐ Craigslist
☐ Email from a North Carolina extension program
☐ Sign
Specify location: __________________________
☐ Other
Specify location: __________________________
☐ Don’t know
In the last 7 days, have you been in close contact with someone who has been diagnosed as having COVID-19 by a healthcare professional?
☐ Yes🡪 Terminate.
☐ No
Have you been diagnosed with COVID-19 in the past 14 days?
☐ Yes🡪 Terminate.
☐ No
Do you have any (one or more) symptoms of COVID-19 such as cough, fever, shortness of breath, chills, muscle pain, new loss of taste or smell?
☐ Yes🡪 Terminate to Covid Screen
☐ No
Are you willing to follow all COVID-19 safety and sanitation procedures while participating in this study including wearing appropriate personal protective equipment?
☐ Yes
☐ No 🡪 Terminate
Do you have any of the following conditions that may increase your risk of serious illness from COVID-19?
☐ Chronic lung disease or moderate to severe asthma
☐ Heart condition
☐ Immunocompromised. (This can result from cancer treatment, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medications)
☐ Body mass index (BMI) of 40 or higher
☐ Diabetes or pre-diabetes
☐ Chronic kidney disease undergoing dialysis
☐ Liver disease
☐ None of the above
Thank you for taking the time to complete this survey to determine your eligibility for this study. We have determined that you are eligible to participate in the study!
Due to the COVID-19 pandemic, there are some additional precautions we must take when you participate in the study. Please be on the lookout for an email from our research team within a few business days regarding how to prepare to come to your study session and what you should expect.
☐ Yes
☐ No 🡪 Terminate.
Great! You qualify for the study. Would you like to participate in the study?
☐ Yes
☐ No 🡪 Terminate.
Script 1 (if no boxes checked in question 20)
Great! We are conducting the study the week of [DATE] between [TIME] and [TIME]. The study will last no more than 2 hours, and you will receive $75 and a small gift for taking part in the study. Please note that additional screening for COVID-19 exposure and symptoms will occur upon arrival which may determine you ineligible at that time. What day and time is convenient for you to participate?
Script 2 (if ANY boxes checked in question 20)
Great! Please enter your name and telephone number so that a study team member can call you and schedule an appointment for the Breakfast Study at a day and time that works best for you. The study will last up to 2 hours, and you will receive a $75 gift card and a small gift for taking part in the study. Please note that additional screening for COVID-19 exposure and symptoms will occur upon arrival which may determine you ineligible at that time. If you’d like, you can download a copy of the consent form here for your review; you will also receive a paper copy upon arrival.
Please note that you have indicated that because of experiences you may be at risk for developing severe illness should you contract COVID-19. Participation in this research requires in-person interaction which may result in contracting COVID-19. Precautions including physical distancing, wearing PPE and cleaning and disinfection, will be taken to mitigate possible transmission of COVID-19; however, you may want to take additional personal precautions.
[SCHEDULE DAY AND TIME]
I have you scheduled for [DATE] at [TIME]. Your participation will take up to 2 hours. The study will be held on NC State’s campus. May I please have your name, telephone number, and email address so we can send you a confirmation email with directions and text message reminders.
[ENTER NAME]
[ENTER TELEPHONE NUMBER]
[ENTER EMAIL ADDRESS].
Thank you for your time.
If you have any questions about the study or need to reschedule or cancel, you may contact [NAME] at [PHONE NUMBER]. If you have concerns about how participants are being treated in the study, you may contact North Carolina State University’s Office of Research Protection at 919-515-4514.
Ineligible/Covid Screen
Thank you for your time. Unfortunately, you are not eligible to take part in our study. Please contact your medical provider to discuss your needs. In addition to contacting your medical provider, if you are an NC State University employee, use this form to self-report: Employee Self-Report Form. If you are an NCSU student, please use this form to report: Student Self Report Form. If you are unaffiliated with NC State University, please call your medical provider to report symptoms.
Ineligible/Terminate Screen
Thank you for your time. Unfortunately, you are not eligible to take part in our study. Have a great day.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0583-0169 and the expiration date is XX/XX/XXXX. The time required to complete this information collection is estimated to average 8 minutes, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. |
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Barrell, Sharon M. |
| File Modified | 0000-00-00 |
| File Created | 2022-03-14 |
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