Screener

Data to Support Drug Product Communications

Screener

OMB: 0910-0695

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OMB Control No. 0910-0695

Expiration date: 3/31/2024


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 0910-0695 and the expiration date is 3/31/2024. The time required to complete this information collection is estimated to average 3 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information.






FDA RAPID – MESSAGE #27

Children’s Cough and Cold

Consumer Update



Introduction

The U.S. Food and Drug Administration, or FDA, hired Westat to help them get opinions about health information. [Plaza Research (parents/caregivers) OR WebMD Professional/Medscape (Pediatric primary care)] is helping Westat and FDA find people who may be interested in being interviewed about health information. To make sure you are a good fit for the interview, please take about 3 minutes to answer the questions below.

1. What is your age?

Under 18 INELIGIBLE

18 to 24

25 to 34

35 to 44

45 to 54

55 or older

2. Are you a healthcare professional?

Yes, physician GO TO Q3

Yes, physician assistant INELIGIBLE

Yes, nurse practitioner INELIGIBLE

Yes, nurse INELIGIBLE

Yes, pharmacist INELIGIBLE

Yes, medical assistant INELIGIBLE

Yes, dietician INELIGIBLE

No GO TO Q5

3. [Ask if Q2 = Yes, physician] Do you specialize in pediatrics?

Yes, pediatric primary care GO TO Q4

Yes, pediatric specialist INELIGIBLE

No INELIGIBLE

4. [Ask if Q3 = Yes, pediatric primary care] In an average year, what percentage of your work time is spent on patient care? Patient care activities include examining patients, performing diagnostic tests, prescribing or dispensing medications, reviewing patient records, and other activities directly connected to treatment. Non-patient care activities include teaching, research, and administration.

50% or more GO TO Q5

Less than 50% INELIGIBLE

5. [Ask if Q4 = 50% or more] Are you an…?

  1. Employee of the U.S. Department of Health and Human Services, or any of its agencies including the Food and Drug Administration, Centers for Disease Control and Prevention, and National Institutes of Health INELIGIBLE

  2. Employee of a state or local health department INELIGIBLE

  3. None of the above GO TO Q7

6. [Ask if Q2 = No] Are you an…?

  1. Employee in a healthcare position or working for a health organization (for example: health consultant, health advocacy) INELIGIBLE

  2. Employee of the U.S. Department of Health and Human Services, or any of its agencies including the Food and Drug Administration, Centers for Disease Control and Prevention, and National Institutes of Health INELIGIBLE

  3. Employee of a state or local health department INELIGIBLE

  4. None of the above GO TO Q7

7. Do you, or does any member of your household or immediate family work…?

  1. For a market research company INELIGIBLE

  2. For an advertising agency, communications, or public relations firm INELIGIBLE

  3. In the media (TV, radio, newspapers, magazines) INELIGIBLE

  4. In the pharmaceutical industry INELIGIBLE

  5. None of the above IF Q5C = None of the above GO TO Q14 IF Q6C = None of the above GO TO Q8

8. [Ask if Q1 = 18 to 54 AND Q2 = No] Are you a parent or guardian of any children?

Yes, one child GO TO Q9

Yes, multiple children GO TO Q9

No INELIGIBLE

9. [Ask if Q8 = Yes, one child OR Yes, multiple children] Are any children living in your household younger than 4 years old?

Yes GO TO Q12

No INELIGIBLE

10. [Ask if Q1 = 55 or older AND Q2 = No] Are you a grandparent who lives with or watches any grandchildren regularly in your own home?

Yes, GO TO Q11

No INELIGIBLE

11. [Ask if Q10 = Yes] Are any grandchildren that you live with or watch regularly younger than 4 years old?

Yes GO TO Q12

No INELIGIBLE

12. [Ask if Q9 = Yes OR Q11 = Yes] In the past 12 months, have you given any cough and cold medicine purchased over-the-counter without a prescription to a child younger than 4 years old?

Yes

No

13. [Ask if Q2 = No] What is the highest grade or level of education you have completed?

  1. Less than High School

  2. High School Diploma or GED

  3. Some College, but no degree

  4. Associate’s Degree INELIGIBLE

  5. Bachelor’s Degree (for example: BA, BS) INELIGIBLE

  6. Graduate or Professional Degree INELIGIBLE

14. What is your sex?

Female

Male

15. Are you of Hispanic, Latino, or Spanish origin?

Yes

No

16. What is your race? Please select one or more.

White

Black or African-American

American Indian or Alaska Native

Asian

Native Hawaiian or other Pacific Islander


17. What state do you live in? [DROP DOWN LIST OF US STATES, INCLUDING “OUTSIDE OF THE US”] [“OUTSIDE OF THE US” INELIGIBLE]



Request for Contact Information

C1. Thank you for answering the questions. Based on your answers, you may be selected for a 45-minute interview. If selected, you will receive [$50 (parents/caregivers) OR $100 (Pediatric primary care)] as a token of appreciation for your participation. At the start of the interview, the interviewer will ask if it’s okay to audio record it. This helps Westat to make sure they correctly hear everything you say. Are you okay with being audio recorded during the interview?

 Yes

 No INELIGIBLE


As stated earlier, [Plaza Research (parents/caregivers) OR WebMD Professional/Medscape (Pediatric primary care)] is helping to identify people interested in providing opinions about health information. If you are chosen for an interview, you will get an email for this study. Make sure you have access to your email during the interview. Is it okay with you for [Plaza Research (parents/caregivers) OR WebMD Professional/Medscape (Pediatric primary care)] to share your contact information with Westat?

 Yes

 No INELIGIBLE

Thank and Terminate

Thank you for taking our survey. Unfortunately, based on your responses, you are not eligible for this study. However, we appreciate you taking the time to answer our questions today.



Contact Information

C2. In the space below, please provide us with your contact information, including phone number and email address. Westat will not share your contact information with anyone else, including the FDA. Your personal information will be deleted upon completion of the research project.



Name ______________________________________________________________________


Phone Number _______________________________________________________________


Email Address ________________________________________________________________



Technology Preferences

C3. The Westat interviewer would like you to share your computer screen during the interview so that you can view the health information together. Westat will send directions for how to do this. Which app do you prefer for screen sharing? [SINGLE SELECT]

  1. Skype

  2. Zoom

  3. WebEx

  4. I am not able to use any of these, please just call me



Closing

Thank you for your answers to these questions. If you are chosen for an interview, someone will contact you within the next 1-2 days.

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorWeinberg, Jessica
File Modified0000-00-00
File Created2022-07-11

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