FDA RAPID_MSG 29_Screener 4-19-2022

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
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of information.

FDA RAPID – MESSAGE #29
COVID Vaccine Q&A and Videos
Introduction
Westat is conducting forty-five minute online interviews on behalf of the U.S.
Food and Drug Administration, or FDA. You will be asked about your opinions
about health information. To make sure you are a good fit for the interview,
please answer the questions below.
BLUE ARROWS AND LANGUAGE INDICATE PROGRAMMING INFORMATION.
PARTICIPANTS WILL NOT SEE THIS LANGUAGE.
1. What is your age?
 Under 18

 INELIGIBLE

 18 to 24
 25 to 34
 35 to 44
 45 to 54
 55 or older
2. Do you, or does any member of your household or immediate family work…?
 For a market research company

 INELIGIBLE

 For an advertising agency, communications, or public relations firm



INELIGIBLE
 In the media (TV, radio, newspapers, magazines)

 INELIGIBLE

 As a healthcare professional (doctor, nurse, pharmacist, medical assistant, dietician,
etc.)

 INELIGIBLE

 In a healthcare position or for a health organization (health consultant, health
advocacy, state or local health department, U.S. Department of Health and Human
Services or any of its agencies)
 In the pharmaceutical industry

 INELIGIBLE
 INELIGIBLE

 GO TO Q3

 None of the above

3. Are you a parent or caregiver of any children under age 16 living in your household?
 Yes, one child

 GO TO Q3

 Yes, multiple children

 GO TO Q4

 No

 GO TO Q9 (note to include some women of

childbearing age in the quota skip pattern)
3. [For parents/caregivers with one child] As of today, please check off the current age of
the child under age 16 living in your household for whom you are a parent or caregiver:
 0 - 4  INELIGIBLE
 5 - 9  GO TO Q5
 10 -11  INELIGIBLE
 12 - 15  GO TO Q5
 16+  INELIGIBLE
4. [For parents/caregivers with multiple children] As of today, please check off the ages
of the children under 16 living in your household for whom you are a parent or caregiver:
□ 0 - 4  INELIGIBLE (IF 5-9 or 12-15 is not selected)
□ 5 - 9  GO TO Q6
□ 10 -11  INELIGIBLE (IF 5-9 or 12-15 is not selected)
□ 12 - 15  GO TO Q6
□ 16+  INELIGIBLE (IF 5-9 or 12-15 is not selected)
5. [If Q3=one child in the range of 5-9 or 12-15] Since February 2022, has your child tested
positive for COVID-19 or have you had a time where you were pretty sure your child had
COVID-19 even if they were not tested?
 Yes  GO TO Q7
 No  GO TO Q7
6. [If Q4=multiple children in range of 5-9 or 12-15] Since February 2022, have any of your
children tested positive for COVID-19 or have you had a time where you were pretty sure
any of your children had COVID-19 even if they were not tested?
 Yes
 No

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7. Has your child or any of your children completed the US–authorized COVID-19
vaccine?
 Yes  GO TO Q12
 No  GO TO Q8
8. [If Q7= No (not vaccinated)] Do you plan to get your child/children vaccinated for
COVID-19?
 Yes  GO TO Q12
 No  GO TO Q12
 Unsure GO TO Q12
9. [If Q2=No, they have no children] Since February 2022, have you tested positive for
COVID-19 or been pretty sure you had COVID-19 even if you were not tested?
 Yes
 No
10. [If Q2=No, they have no children] Which of the following have you done?
a. Completed a US-authorized COVID-19 vaccine  GO TO Q12 (Quota: 4 of 10)
b. Completed a US-authorized COVID-19 vaccine and a BOOSTER DOSE  GO TO
Q12 (Quota: 3 of 10)
c. Neither initiated nor completed a COVID-19 vaccine  GO TO Q11 (Quota: 3 of 10)
11. [If Q10=c (not vaccinated)] Do you plan to get vaccinated for COVID-19?
 Yes
 No
 Unsure
12. What is the highest grade or level of education you have completed?
 Less than High School
 High School Diploma or GED
 Some College, but no degree
 Associate’s Degree
 Bachelor’s Degree (for example: BA, BS)

3

 INELIGIBLE

 Graduate or Professional Degree
13. What is your sex?
 Female
 Male
 Prefer not to answer
14. Are you of Hispanic, Latino, or Spanish origin?
 Yes
 No
15. What is your race? Please select all that apply.
□ White
□ Black or African-American
□ American Indian or Alaska Native
□ Asian
□ Native Hawaiian or other Pacific Islander

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

17. Do you have access to high-speed (in other words, not dial-up) internet?
 Yes
 No

 INELIGIBLE

18. For this discussion, the interviewer would like to share her computer screen during
the interview so that you can view the health information together. Do you have a
computer (laptop, tablet, or desktop) with a webcam and audio that you can use to
participate?
 Yes
 No

 INELIGIBLE

19. Have you participated in an interview or focus group for a research study within the
past 6 months?
 Yes
 INELIGIBLE

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 No
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 a digital gift card of [$50
(parents/caregivers/adults)] 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

Contact Information
In the space below, please provide us with your contact information, including phone
number and email address. PRC 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 ________________________________________________________________

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.
[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.

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