Form 0920-20PJ Telephone Screening

Attachment D. Telephone Screening

Form Approved

OMB No: 0920-xxxx
Exp. Date: xx-xx-xxxx

Public Reporting burden of this collection of information is estimated at 25 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 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 NW, MS D-74, Atlanta, GA  30333; Attn:  PRA (0920-xxxx).

Telephone Screening

Thank you for your interest in this research study. We are collecting information to learn about the community supports and resources that are helpful to children and families affected by opioids and the use of other substances in tribal communities. Participation in this study would involve joining a focus group or interview and completing a brief survey.

We will ask you some questions to see if you are eligible to participate. Some questions might be personal or sensitive. They are important to the study and we would like you to answer them honestly. Any information you share with me today will be kept confidential, private, and will only be used to determine if you are eligible for the study. If there are some questions you do not want to answer, you may skip them. You can stop this conversation at any time. If you do not qualify for this study, the information you share with me today will be deleted immediately and we will not use it. Do I have your permission to proceed?

A. Telephone Screening
How old are you?	17 years or younger [thank individual for their time and inform of ineligibility] 18 to 24 years (young adult) 25 or older	Refused [thank individual for their time and inform of ineligibility] I don’t know [thank individual for their time and inform of ineligibility]
Opioids are prescription medications often referred to as painkillers or they can be street drugs such as heroin. Remember that anything you share with me today will be kept confidential and private. Have you been affected by the opioid epidemic (i.e., directly by self-use, family member, or close friend’s use in that children were removed from the home either formally or informally)?	Yes No [thank individual for their time and inform of ineligibility] Refused [thank individual for their time and inform of ineligibility] I don’t know [thank individual for their time and inform of ineligibility]
Which of these roles describes you? You can select more than one. For this project, we are considering “community leaders”, as those who provide indirect services to the local American Indian community. This might include an administrator from an American Indian organization, a local teacher or professor that engages the American Indian community in educational efforts, or a local individual who serves as a non-elected leader in the community.	Tribal Elder	Yes	No
	Tribal Leader	Yes	No
	Traditional Healer	Yes	No
	Young adult (18 to 24 years)	Yes	No
	Service provider	Yes	No
	Community leader	Yes	No
	Parent of child(ren) under 18	Yes	No
	Refused [thank individual for their time and inform of eligibility]	Yes	No
[For parents of child(ren) under 18 years] are your child(ren) American Indian or Alaska Native?	Yes No [thank individual for their time and inform of ineligibility] Skip this question [thank individual for their time and inform of ineligibility] I don’t know [thank individual for their time and inform of ineligibility]
[For service providers] are you a public health, behavioral health, and/or other service provider in the community?	Yes No [thank individual for their time and inform of ineligibility] Refused [thank individual for their time and inform of ineligibility] I don’t know [thank individual for their time and inform of ineligibility]
[For young adults (18 to 24 years)] do you have prior experiences in the following? You can select more than one.	Involvement in the foster care system Removed from the home by CPS and placed with family Justice involvement Residential Indian boarding school Youth regional treatment center	No [thank individual for their time and inform of ineligibility] Refused [thank individual for their time and inform of ineligibility] I don’t know [thank individual for their time and inform of ineligibility]
[For Tribal Elders, Tribal leaders, traditional healers and young adults] do you self-identify as American Indian or Alaska Native?	Yes No [thank individual for their time and inform of ineligibility]	Skip this question [thank individual for their time and inform of ineligibility] I don’t know [thank individual for their time and inform of ineligibility]

Contact Information and accommodations [separate from screening information]

You are eligible to participate in the study. Before I gather any more information from you, I want to share some information with you and see if you have any questions for me about the study or being a study participant. As a participant in this study, you will be asked to join a(n) [interview/focus group]. Your [interview/focus group] will last up to two hours and may be in person or on an online meeting or over the phone. If in person, you will be asked to travel to a location within the community where the [interview/focus group] will take place. We will do all we can to keep everything you share completely private. We will not share your responses with anyone without your permission. We will not share anyone else’s responses with you. You will receive $75 for the costs associated with your participation, such as childcare and/or transportation. This study is funded by the Centers for Disease Control and Prevention and the results will contribute to a growing body of knowledge around how the resiliency and strengths of tribal communities support the health and wellbeing of children and families.

Do you have any questions for me? [Open up for questions]

Great. Thank you for your questions. If you are still interested in participating, we will need your name and contact information for scheduling purposes, and the names of one or two people who know how to reach you in the event you move or your contact information changes before your visit takes place. The information you share with me will be contained in a secure database. It will not be shared with the CDC and will be deleted or destroyed by September 2023. Are you still interested in participating? [If no, thank individual for their time.]

B. Contact Information
What is your name?
What is your mailing address?
What is your personal phone number?
What is your email address?
What is the name and phone number for one or two people who know how to reach you?

We have the following dates and times available for an [interview/focus group] [insert information]- which one works for you? [Explain that it will be in person (and give location) or virtual (online platform or phone).

[If the data are being collected virtually for this site] We are planning to host this discussion using the Internet-based meeting platform [insert platform]. Do you feel like your Internet can support a 2-hour online video meeting? Can you stream services like Netflix or Internet gaming? Or can you use video chats on Facebook or Skype using your Internet? Even when multiple people in the home are online?

[If no] Okay, you can either join the online discussion over the phone or find a safe, private, and quiet meeting space with reliable Internet to go to for this discussion. Which would work best for you?

[If phone, share that you will include phone information for them to dial into the meeting. If traveling to another space, ask if they need support finding a space with reliable Internet.]

We will send you a confirmation email and/or letter one week before your [interview/focus group], do you prefer an email, letter, or both?

We will send a reminder email/call/text the day before your [interview/focus group], do you prefer an email, call, text, or more than one?

Do you think you will need any support reading through the consent form and survey ahead of the [interview/focus group]? [If yes, offer to read the consent form and survey over the phone now or schedule a separate call; or ask that they arrive at the focus group/interview 15 minutes early, where a researcher will help them read through the documents in person.]

Lastly, do you know anyone else who may be interested in participating in this study? [If yes] May I contact them, or would you mind sharing my contact information with them? [Record contact information if provided]

Please let us know as soon as possible if you need to reschedule your [interview/focus group] - we would be happy to find a date/time that will work for you. If you change your mind about participating, please let us know that as well, so we can fill your spot. We can be reached at this phone number [insert information] or email [insert information] if you have any questions. Thank you!