Recruitment Screener - Phone

Data to Support Drug Product Communications

Recruitment Screener - Phone

OMB: 0910-0695

Document [docx]
Download: docx | pdf

Shape1

OMB# 0910-0695
Exp. 3/31/2024



Studies to Enhance FDA Communications Addressing Biosimilar Drug Products:

Patient Interview Screener


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 5 minutes per response to answer the questions to determine eligibility.

[Only read above if respondent asks about the OMB control number]


Biosimilars Patient Study

Phase 2 Telephone Screener


Introduction


Hello, my name is _____________ from L&E Research. May I please speak to_____________? I’m calling to invite you to participate in an online interview sponsored by the U.S. Food and Drug Administration to get your feedback on health-related materials about a specific type of medicine.


The interview will be led by a researcher through an online video platform, and if you’re eligible, you can participate from home using a computer and web camera. The discussion will last about 90 minutes. You will be emailed about your $75 honorarium within one business day after the interview concludes and have the option to choose between a physical or electronic gift card.


May I ask you a few questions now to see if you are eligible?

  • Yes CONTINUE

  • No THANK AND TERMINATE [See closing scripts at end of screener]


Core Eligibility Questions

  1. What is your age?

Age 18 or older

CONTINUE

Under 18

TERMINATE

___ years

  1. Have you ever worked…? [Read list. Accept multiple responses.]

    For a drug or pharmaceutical company

    TERMINATE

    For a market research or marketing company, including RTI International or L&E Research

    TERMINATE

    For the U.S. federal government (not including as a member of the military)

    TERMINATE

    As a medical professional (such as a physician, nurse, or pharmacist)

    TERMINATE

    None of the above

    CONTINUE

  2. When was the last time you participated in an interview or a focus group for a research study?

    Within the last 6 months

    TERMINATE

    More than 6 months ago

    CONTINUE

    Never

    CONTINUE

    Don’t know

    TERMINATE

  3. To participate in this study, you will need a desktop computer, laptop computer, or a tablet, not just a smartphone. Which type of device are you most likely to use if you participate in the study?

    Desktop computer

    CONTINUE

    Laptop computer

    CONTINUE

    Tablet (e.g., iPad)

    CONTINUE

    I don’t have any of the devices listed above

    TERMINATE

  4. To participate in this study, you will also need a webcam attached or built into the device and high-speed internet access. Can you meet these requirements?

    Yes

    CONTINUE

    No

    TERMINATE

  5. Do you have any vision, hearing, or speaking issues that would prevent you from reviewing English-language written materials and videos during the interview?

    Yes

    TERMINATE

    No

    CONTINUE

  6. Are you ok with being audio and video recorded during the interview?

Yes

CONTINUE

No

TERMINATE


Audience Segmentation Questions

  1. Has a healthcare professional ever diagnosed you with any of the following medical conditions? [Read list of conditions. Only read detailed description of a condition if requested by individual. Accept multiple responses.]

Ankylosing spondylitis / Spondyloarthritis

Inflammatory disease that can cause vertebrae in the spine to fuse.

Ask Q9, then CONTINUE to Q14

Psoriatic arthritis

A form of arthritis that affects some people who have psoriasis.

Ask Q9, then CONTINUE to Q14

Rheumatoid arthritis

A chronic inflammatory disorder that can affect joints and other body systems.

Ask Q9, then CONTINUE to Q14

Cancer

A variety of conditions involving abnormal cell growth.

Ask Q9, then CONTINUE to Q10

Crohn’s disease

A bowel disease involving inflammation of the digestive tract.

Ask Q9, then CONTINUE to Q14

Ulcerative colitis

A bowel disease that affects the large intestine with inflammation and ulcers or sores.

Ask Q9, then CONTINUE to Q14

Eczema / Atopic dermatitis

A skin condition involving itchy rashes.

Ask Q9, then CONTINUE to Q14

Psoriasis

A chronic skin condition where cells build up rapidly on the skin, forming itchy and sometimes painful scaly red patches.

Ask Q9, then CONTINUE to Q14

Type 1 diabetes

A chronic condition in which the pancreas produces little or no insulin.

Ask Q9, then CONTINUE to Q12

Type 2 diabetes

A disease that occurs when not enough insulin is produced or when your body has difficulty using insulin properly.

Ask Q9, then CONTINUE to Q12

None of the above

SKIP to Q14


  1. How long ago were you diagnosed with [condition]? [Ask for each condition selected by respondent]

___ years

___ months (if less than 1 year)




Segmentation Questions – Cancer

  1. Which type(s) of cancer were you diagnosed with? [Accept multiple responses]

    Breast

    CONTINUE

    Colorectal

    CONTINUE

    Kidney

    CONTINUE

    Leukemia

    CONTINUE

    Lung

    CONTINUE

    Lymphoma

    CONTINUE

    Myeloma

    CONTINUE

    Skin

    CONTINUE

    Other (please specify)

    CONTINUE

  2. Have you ever been diagnosed by a healthcare professional with neutropenia, a blood-related side effect of chemotherapy?

Yes

CONTINUE to Q14

No

CONTINUE to Q14



Segmentation Questions – Diabetes

  1. How long have you been using insulin to treat your diabetes? [Read list]

    More than one month

    CONTINUE

    Less than one month

    SKIP to Q14

    Not currently taking insulin

    SKIP to Q14

  2. Do you take insulin at least once per day?

Yes

CONTINUE to Q14

No

CONTINUE to Q14



Segmentation Questions – Children with Diabetes

  1. Are you the parent or guardian of a child who has been diagnosed with diabetes by a healthcare professional? If so, which type of diabetes?

    Yes, type 1 diabetes

    CONTINUE

    Yes, type 2 diabetes

    CONTINUE

    No

    SEE Q19 INSTRUCTIONS

  2. What is this child’s age?

___ years



Age 18 or older

TERMINATE IF Q8=None of the above

Under 18

CONTINUE



  1. How involved are you in managing your child’s diabetes, for example, scheduling doctor’s appointments, making medication decisions, and administering insulin? Would you say you are...? [Read list]

    Extremely involved

    CONTINUE

    Frequently involved

    CONTINUE

    Somewhat involved

    SEE Q19 INSTRUCTIONS

    Not at all involved

    SEE Q19 INSTRUCTIONS

  2. How long has your child been using insulin to treat his or her diabetes? [Read list]

    More than one month

    CONTINUE

    Less than one month

    SEE Q19 INSTRUCTIONS

    Not currently taking insulin

    SEE Q19 INSTRUCTIONS

  3. Does your child take insulin at least once per day?

Yes

SEE SKIP PATTERN BELOW

No

SEE SKIP PATTERN BELOW

[Skip pattern:

    • If individual’s responses have checked one or more of the yellow boxes, proceed to Q19.

    • If individual’s responses have checked only the green boxes, skip to Q24.

    • If no yellow or green boxes selected, terminate and read closing script.]



MEDICATION QUESTIONS

  1. Now I’d like to ask about medicines that you take for your health conditions. Have you ever taken one or more of the following medicines to treat [list condition(s) for a max of three condition(s) based on responses to Q8, Q10, and Q11]?

[Read list of medicines for each applicable medical condition. Do NOT read “Biosimilar” flag next to medication name.]

[Record multiple responses. If one or more medications selected, continue to Q20. If no medications selected, terminate.]

[RECRUIT AT LEAST 20% TAKING AT LEAST ONE BIOSIMILAR]

Selected one or more medicines

CONTINUE

Did not select any medicines for applicable conditions

TERMINATE

List of Medicines for Q19

Condition

Medicines

Brand Name [pronunciation] [generic Name]

Ankylosing Spondylitis/ Spondyloarthritis

  • Avsola [av-SO-luh] [infliximab-axxq] (biosimilar)

  • Cimzia [SIM-zi-ah] [certolizumab]

  • Cosentyx [koh-SEN-tix] [secukinumab]

  • Enbrel [EN-brel] [etanercept]

  • Erelzi [Ee-REL-zee] [etenercept-szzs] (biosimilar)

  • Eticovo [Et-uh-co-vo] [etanercept-ykro] (biosimilar)

  • Humira [hu-MEER-ah] [adalimumab]

  • Inflectra [In-flec-tra] [infliximab-dyyb] (biosimilar)

  • Ixifi [ix-IF-ee] [infliximab-qbtx] (biosimilar)

  • Remicade [REM-i-cade] [infliximab]

  • Renflexis [ren-FLEX-is] [infliximab-abda] (biosimilar)

  • Simponi [SIM-poh-nee] [golimumab]

  • Taltz [Taltz] [xekixumab]

Psoriatic Arthritis

  • Avsola [av-SO-luh] [infliximab-axxq] (biosimilar)

  • Cimzia [SIM-zi-ah] [certolizumab]

  • Cosentyx [koh-SEN-tix] [secukinumab]

  • Enbrel [EN-brel] [etanercept]

  • Erelzi [Ee-REL-zee] [etenercept-szzs] (biosimilar)

  • Eticovo [Et-uh-co-vo] [etanercept-ykro] (biosimilar)

  • Humira [hu-MEER-ah] [adalimumab]

  • Inflectra [In-flec-tra] [infliximab-dyyb] (biosimilar)

  • Ixifi [ix-IF-ee] [infliximab-qbtx] (biosimilar)

  • Orencia [oh-REN-see-ah] [abatacept]

  • Otezla [oh-TEZ-la] [apremilast]

  • Remicade [REM-i-cade] [infliximab]

  • Renflexis [ren-FLEX-is] [infliximab-abda] (biosimilar)

  • Simponi [SIM-poh-nee] [golimumab]

  • Simponi Aria [golimumab], IV Infusion

  • Stelara [stuh-LAIR-ah] [ustekinumab]

  • Taltz [Taltz] [xekixumab]

  • Xeljanz [ZEL-janz] [tofacitinib]




Rheumatoid Arthritis

  • Actemra [ac-tEm-ra] [tocilizumab]

  • Avsola [av-SO-luh] [infliximab-axxq] (biosimilar)

  • Cimzia [SIM-zi-ah] [certolizumab]

  • Cosentyx [koh-SEN-tix] [secukinumab]

  • Enbrel [EN-brel] [etanercept]

  • Erelzi [Ee-REL-zee] [etenercept-szzs] (biosimilar)

  • Eticovo [Et-uh-co-vo] [etanercept-ykro] (biosimilar)

  • Humira [hu-MEER-ah] [adalimumab]

  • Inflectra [In-flec-tra] [infliximab-dyyb] (biosimilar)

  • Ixifi [ix-IF-ee] [infliximab-qbtx] (biosimilar)

  • Kevzara [kev-ZAR-a] [sarilumab]

  • Kineret [KIN-er-et] [anakinra]

  • Orencia [oh-REN-see-ah] [abatacept]

  • Remicade [REM-i-cade] [infliximab]

  • Renflexis [ren-FLEX-is] [infliximab-abda] (biosimilar)

  • Rinvoq [RIN-voke] [upadacitinib]

  • Rituxan [rih-TUK-sun] [rituximab]

  • Stelara [stuh-LAIR-ah] [ustekinumab]

  • Simponi [SIM-poh-nee] [golimumab]

  • Xeljanz [ZEL-janz] [tofacitinib]




Cancer (leukemia)

  • Arzerra [ar-ZAYR-uh] [ofatumumab]

  • Asparlas [AS-par-las] [calaspargase pegol-mknl]

  • Besponsa [beh-SPON-suh] [inotuzumab ozogamicin]

  • Blincyto [blin-sye-toe] [blinatumomab]

  • Campath [KAM-path] [alemtuzumab]

  • Copiktra [koh-PIK-truh] [duvelisib]

  • Daurismo [DOOR-is-moh] [glasdegib]

  • Elspar [EL-spar] [asparaginase]

  • Erwinaze [ER-wih-nayz] [asparaginase erwinia chrysanthemi]

  • Gazyva [guh-ZY-vuh] [obinutuzumab)

  • Intron A [IN-tron-Aye] [interferon alfa-2b]

  • Kymriah [kim-rye-ah] [tisagenlecleucel]

  • Lumoxiti [loo-MOK-sih-tee] [moxetumomab pasudotox-tdfk]

  • Mylotarg [MY-loh-targ] [gemtuzumab ozogamicin]

  • Oncaspar [ON-kah-spar] [pegaspargase]

  • Riabni [re-AB-nee] [rituximab-arrx] (biosimilar)

  • Rituxan [rih-TUK-sun] [rituximab]

  • Rituxan Hycela [rih-TUK-sun hy-SEL-uh] [rituximab and hyaluronidase human]

  • Ruxience [RUKS-ee-ents] [rituximab-pvvr] (biosimilar)

  • Truxima [truk-SEE-muh] [rituximab-abbs] (biosimilar)

  • Venclexta [ven-KLEK-stuh] [venetoclax]

  • Xospata [zoh-SPAH-tuh] [gilteritinib]




Cancer (blood – including lymphoma and myeloma)

  • Adcetris [ad-SEH-tris] [brentuximab vedotin]

  • Blenrep [BLEN-rep] [belantamab mafodotin-blmf]

  • Darzalex [DAR-zah-lex] [daratumumab]

  • Darzalex Faspro [DAR-zah-lex Fass-pro] [daratumumab and hyaluronidase-fihj]

  • Empliciti [em-PLIH-sih-tee] [elotuzumab]

  • Epogen [EE-po-jen] [epoetin alfa]

  • Erwinaze [ER-wih-nayz] [asparaginase erwinia chrysanthemi]

  • Gazyva [guh-ZY-vuh] [obinutuzumab]

  • Keytruda [key-true-duh] [pembrolizumab]

  • Kymriah [kim-rye-ah] [tisagenlecleucel]

  • Monjuvi [mon-JOO-vee] [tafasitamab-cxix]

  • Ontak [ON-tak] [denileukin diftitox]

  • Polivy [poh-LIH-vee] [polatuzumab vedotin-piiq]

  • Procrit [PROH-crit] [epoetin alfa]

  • Retacrit [RET-a-crit] [epoetin alfa-epbx]

  • Riabni [re-AB-nee] [rituximab-arrx] (biosimilar)

  • Rituxan [rih-TUK-sun] [rituximab]

  • Rituxan Hycela [rih-TUK-sun hy-SEL-uh] [rituximab and hyaluronidase human]

  • Ruxience [RUKS-ee-ents] [rituximab-pvvr] (biosimilar)

  • Sarclisa [sar-KLIH-suh] [isatuximab-irfc]

  • Tecartus [tek-AR-tus] [brexucabtagene autoleucel]

  • Truxima [truk-SEE-muh] [rituximab-abbs] (biosimilar)

  • Zevalin [ZEH-vuh-lin] [ibritumomab tiuxetan]




Cancer (lung)

  • Avastin [uh-VAST-in] [bevacizumab]

  • Bavencio [buh-VEN-see-oh] [avelumab]

  • Cyramza [sy-RAM-zuh] [ramucirumab]

  • Epogen [EE-po-jen] [epoetin alfa]

  • Imfinzi [im-FIN-zee] [durvalumab]

  • Keytruda [key-true-duh][pembrolizumab]

  • Lorlatinib [lor-LA-ti-nib] [lorlatinib]

  • Mvasi [em-VAH-see] [bevacizumab-awwb] (biosimilar)

  • Opdivo [op-DEE-voh] [nivolumab]

  • Portrazza [por-TRA-zuh] [necitumumab]

  • Procrit [PROH-crit] [epoetin alfa]

  • Retacrit [RET-a-crit] [epoetin alfa-epbx]

  • Tecentriq [teh-SEN-trik] [atezolizumab]

  • Vizimpro [vih-ZIM-proh] [dacomitinib]

  • Zirabev (bevacizumab-bvzr) (biosimilar)




Cancer (skin—melanoma, squamous cell carcinoma, basal cell carcinoma)

  • Alferon N [al-FEER-on N] [interferon alfa-n3]

  • Braftovi [braf-TOH-vee] [encorafenib]

  • Keytruda [key-true-duh] [pembrolizumab]

  • Libtayo [lib-TY-oh] [cemiplimab-ydhp]

  • Opdivo [op-DEE-voh] [nivolumab]

  • Mektovi [mek-TOH-vee] [binimetinib]

  • Proleukin [proh-LOO-kin] [aldesleukin]

  • Yervoy [YER-voy] [ipilimumab]




Cancer (colorectal)

  • Avastin [uh-VAST-in] [bevacizumab]

  • Cyramza [sy-RAM-zuh] [ramucirumab]

  • Erbitux [ER-bih-tux] [cetuximab]

  • Mvasi [em-VAH-see] [bevacizumab-awwb] (biosimilar)

  • Vectibix [VEK-tih-bix] [panitumumab]

  • Yervoy [YER-voy] [ipilimumab]

  • Zaltrap [ZAL-trap] [ziv-aflibercept]

  • Zirabev [ZIE-rah-bev] [bevacizumab-bvzr] (biosimilar)




Cancer (breast)

  • Epogen [EE-po-jen] [epoetin alfa]

  • Herceptin [her-SEP-tin] [trastuzumab]

  • Herzuma [her-ZOO-muh] [trastuzumab-pkrb] (biosimilar)

  • Kadcyla [kad-SY-luh] [ado-trastuzumab emtansine]

  • Kanjinti [kan-jin-tee] [trastuzumab-anns] (biosimilar)

  • Margenza [MAR-jen-zuh] [margetuximab-cmkb]

  • Ogivri [oh-GIV-ree] [trastuzumab-dkst] (biosimilar)

  • Ontruzant [on-TRU-zant] [trastuzumab-dttb] (biosimilar)

  • Perjeta [per-JEH-tuh] [pertuzumab]

  • Phesgo [FES-goh] [pertuzumab, trastuzumab, and hyaluronidase-zzxf]

  • Procrit [PROH-crit] [epoetin alfa]

  • Retacrit [RET-a-crit] [epoetin alfa-epbx]

  • Talazoparib [TA-luh-ZOH-puh-rib] [talazaoparib]

  • Tecentriq [teh-SEN-trik] [atezolizumab]

  • Trazimera [tra-zee-MER-uh] [trastuzumab-qyyp] (biosimilar)

  • Trodelvy [troh-DEL-vee] [sacituzumab govitecan-hziy]




Cancer (kidney)

  • Avastin [uh-VAST-in] [bevacizumab]

  • Mvasi [em-VAH-see] [bevacizumab-awwb] (biosimilar)

  • Opdivo [op-DEE-voh] [nivolumab]

  • Proleukin [proh-LOO-kin] [aldesleukin]

  • Yervoy [YER-voy] [ipilimumab]

  • Zirabev (bevacizumab-bvzr) (biosimilar)




Cancer (other types)

  • Avastin [uh-VAST-in] [bevacizumab]

  • Cyramza [sy-RAM-zuh] [ramucirumab]

  • Danyelza [dan-YEL-zah] [naxitamab-gqg]

  • Elzonris [el-ZON-ris] [tagraxofusp-erz]

  • Epogen [EE-po-jen] [epoetin alfa]

  • Erbitux [ER-bih-tux] [cetuximab]

  • Keytruda [key-true-duh] [pembrolizumab]

  • Lartruvo [lar-TROO-voh] [olaratumab]

  • Lenvima [len-VEE-muh] [lenvatinib]

  • Lynparza [lin-PAR-zuh] [olaparib]

  • Mvasi [em-VAH-see] [bevacizumab-awwb] (biosimilar)

  • Poteligeo [poh-teh-LIH-gee-oh] [mogamuliziumab]

  • Procrit [PROH-crit] [epoetin alfa]

  • Retacrit [RET-a-crit] [epoetin alfa-epbx]

  • Tecentriq [teh-SEN-trik][atezolizumab]

  • Zirabev (bevacizumab-bvzr) (biosimilar)




Neutropenia (from cancer treatment)

  • Fulphila [FUL-fih-luh] [pegfilgrastim-jmdb] (biosimilar)

  • Granix [GRA-nix] [tbo-filgrastim]

  • Neulasta [noo-LA-stuh] [pegfilgrastim]

  • Neupogen [NOO-poh-jen] [filgrastim]

  • Nivestym [NAI-vuh-stim] [filgrastim-aafi] (biosimilar)

  • Nyvepria [NAI-vee-pri-ah] [pegfilgrastim-apgf] (biosimilar)

  • Udenyca [yoo-den-i-kah] [pegfilgrastim-cbqv] (biosimilar)

  • Zarxio [ZAR-zee-oh] [filgrastim-sndz] (biosimilar)

  • Ziextenzo [zee-ex-TEN-zo] [pegfilgrastim-bmez] (biosimilar)




Crohn's Disease

  • Avsola [av-SO-luh] [infliximab-axxq] (biosimilar)

  • Cimzia [SIM-zi-ah] [certolizumab]

  • Entyvio [en-TIV-ee-oh] [vedolizumab]

  • Humira [hu-MEER-ah] [adalimumab]

  • Inflectra [In-flec-tra] [infliximab-dyyb] (biosimilar)

  • Ixifi [ix-IF-ee] [infliximab-qbtx] (biosimilar)

  • Remicade [REM-i-cade] [infliximab]

  • Renflexis [ren-FLEX-is] [infliximab-abda] (biosimilar)

  • Stelara [ustekinumab]

  • Tysabri [tai-SAB-ree] [natalizumab]




Ulcerative Colitis

  • Avsola [av-SO-luh] [infliximab-axxq] (biosimilar)

  • Entyvio [en-TIV-ee-oh] [vedolizumab]

  • Humira [hu-MEER-ah] [adalimumab]

  • Inflectra [In-flec-tra] [infliximab-dyyb] (biosimilar)

  • Ixifi [ix-IF-ee] [Infliximab-qbtx] (biosimilar)

  • Remicade [REM-i-cade] [infliximab]

  • Renflexis [ren-FLEX-is] [infliximab-abda] (biosimilar)

  • Simponi [SIM-poh-nee] [golimumab]

  • Stelara [stuh-LAIR-ah] [ustekinumab]

  • Xeljanz [ZEL-janz] [tofacitinib]




Eczema/Atopic Dermatitis

  • Dupixent [due-PIX-ent] [dupilumab]


Psoriasis

  • Avsola [av-SO-luh] [infliximab-axxq] (biosimilar)

  • Cimzia [SIM-zi-ah] [certolizumab]

  • Cosentyx [koh-SEN-tix] [secukinumab]

  • Enbrel [EN-brel] [etanercept]

  • Erelzi [Ee-REL-zee] [etanercept-szzs] (biosimilar)

  • Eticovo [Et-uh-co-vo] [etanercept-ykro] (biosimilar)

  • Humira [hu-MEER-ah] [adalimumab]

  • Ilumya [e-loom-e-a] [tildrakizumab]

  • Inflectra [In-flec-tra] [infliximab-dyyb] (biosimilar)

  • Ixifi [ix-IF-ee] [infliximab-qbtx] (biosimilar)

  • Otezla [oh-TEZ-la] [apremilast]

  • Remicade [REM-i-cade] [infliximab]

  • Renflexis [ren-FLEX-is] [infliximab-abda] (biosimilar)

  • Siliq [sill-EEK] [brodalumb]

  • Skyrizi [sky-RI-zee] [risankizumab]

  • Stelara [stuh-LAIR-ah] [ustekinumab]

  • Taltz [taltz] [lxekizumab]

  • Tremfya [trem-FAI-ah] [guselkumab]

  1. Are you still taking [list biologics selected in Q19, one at a time]? [Record response for each medicine]

    Yes

    CONTINUE

    No

    SKIP TO Q22 IF NO TO ALL MEDS

  2. How long have you been taking [list biologics currently taking, one at a time]? [Record response for each medicine]

    Less than one month

    TERMINATE

    1-3 months

    CONTINUE to Q22

    4-6 months

    CONTINUE to Q22

    7-12 months

    CONTINUE to Q22

    More than one year

    CONTINUE to Q22

  3. When did you last take [list biologics selected in Q19 that individual is not currently taking, one at a time]? [Record response for each medicine]

    Within the last month

    CONTINUE

    1-3 months ago

    CONTINUE

    4-6 months ago

    CONTINUE

    More than 6 months ago


    TERMINATE

  4. How long did you take [list of biologics selected in Q19 that individual is not currently taking, one at a time] when you were still using it? [Record response for each medicine]

    Less than one month

    TERMINATE

    More than one month

    CONTINUE to Q24

  5. Would you be comfortable discussing this medicine/these medicines in an interview?

Yes

ELIGIBLE

No

TERMINATE



Demographic Questions

  1. What is the highest level of education you have completed? [Read list]

  • Less than high school diploma [Eligible for lower education groups]

  • High school graduate or GED [Eligible for lower education groups]

  • Some college

  • Technical or Associates degree (2-year)

  • 4-year degree

  • Graduate or professional degree [RECRUIT NO MORE THAN 14% OF SAMPLE]

  1. What type of health insurance do you currently have? [Read list. Accept multiple responses]

  • Private insurance through an employer, group health plan, broker, agent, or Federal or state marketplace plan

  • Medicaid or Medicare [RECRUIT AT LEAST 30% OF TOTAL SAMPLE NON-PRIVATE]

  • Veterans Affairs, Tricare, or the Department of Defense [RECRUIT AT LEAST 30% OF TOTAL SAMPLE NON-PRIVATE]

  • Currently uninsured

  • Other [please specify]: _______________________

  1. What is your race? You may select more than one. [Read list. Accept multiple responses]

  • White [RECRUIT NO MORE THAN 80% OF SAMPLE]

  • Black or African American

  • Asian

  • Native Hawaiian or Other Pacific Islander

  • American Indian or Alaska Native

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

  • Yes [RECRUIT AT LEAST 15% OF SAMPLE]

  • No

  1. In which state do you live? [Record response, then sort into corresponding Census region]

Record participant response: ________

  • Midwest - IL, IN, IO, KS, MI, MN, MO, NE, ND, OH, SD, WI [RECRUIT AT LEAST 20% OF SAMPLE]

  • Northeast - CT, MA, ME, NH, NJ, NY, PA, RI, VT [RECRUIT AT LEAST 20% OF SAMPLE]

  • South - AL, AR, DC, DE, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV [RECRUIT AT LEAST 20% OF SAMPLE]

  • West - AK, AZ, CA, CO, HI, ID, NM, MT, OR, UT, NV, WA, WY [RECRUIT AT LEAST 20% OF SAMPLE]

  1. What was your total household income before taxes during the past 12 months? Your response will be kept private.

  • $30,000 or less [RECRUIT AT LEAST 20% OF SAMPLE < $30,000]

  • $30,001 to $65,000

  • $65,001 to $99,999

  • More than $100,000

  • Prefer not to answer

  1. What is your sex?

  • Male [RECRUIT AT LEAST 40% OF SAMPLE]

  • Female [RECRUIT AT LEAST 40% OF SAMPLE]



Closing Scripts

Ineligible - Closing Script

I’m sorry, but you are not eligible for this study. There are many possible reasons why people are not eligible. These reasons were decided earlier by the researchers. However, thank you for your interest in this study and for taking the time to answer our questions today.

Eligible – Closing Script

Thank you for answering my questions. You qualify for our study. Next, I’d like to schedule you for an online interview. The interview will last about 90 minutes. You will be emailed about your $75 honorarium within one business day after the interview concludes and have the option to choose between a physical or electronic gift card.


The interviews will take place on [DATES AND TIMES]. Which date and time would work best for you? [Schedule participant for an appropriate interview]

The e-mail address I have on file for you is [E-MAIL ADDRESS] and phone number is [PHONE NUMBER]. Are those still correct? [UPDATE IF NEEDED]

We will reach out with a confirmation email and phone call with instructions to join the interview on [DATE/TIME]. We will also use this information to send you a reminder email and to call and remind you of the interview one day before.

Your participation in this study is very important. If for some reason you will not be able to attend, please let us know right away. You can call us anytime at [insert phone number], and if we are not here, please leave a message.

Thank you. We appreciate your participation in this study.





11


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

© 2024 OMB.report | Privacy Policy