Download:
pdf |
pdf+Change Sailors - Interview Screen
Start of Block: Privacy Act Statement
OMB CONTROL NUMBER: 0703-0080
OMB EXPIRATION DATE: 08/31/2022
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0703-0080, is estimated to
average 105 minutes per response (5, 90, and 10 minutes for pre-survey, interview/focus
group, and post-survey, respectively), including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding the burden estimate or
burden reduction suggestions to the Department of Defense, Washington Headquarters
Services, at [email protected]. Respondents
should be aware that notwithstanding any other provision of law, no person shall be subject to
any penalty for failing to comply with a collection of information if it does not display a currently
valid OMB control number.
Privacy Act Statement This statement serves to inform you of the purpose for collecting
personal information required by this system and how it will be used.
AUTHORITY: 10 U.S.C. Chapter 55, Medical and Dental Care; 32 CFR 199.17, TRICARE
program; and E.O. 9397 (SSN), as amended.
PURPOSE: To collect information from Navy service members in order to create a sexual
assault prevention and alcohol reduction intervention specific to Sailors ages 18-24
ROUTINE USES: Use and disclosure of your records outside of DoD may also occur in
accordance with the DoD Blanket Route Uses published at
http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html and as permitted by the
Privacy Act of 1974, as amended (5 U.S.C. 552a(b)). Any protected health information (PHI) in
your records may be used and disclosed generally as permitted by the HIPAA Privacy Rule (45
CFR Parts 160 and 164), as implemented within DoD. Permitted uses and disclosures of PHI
include, but are not limited to, treatment, payment, and healthcare operations.
DISCLOSURE: Voluntary; however, failure to provide information may result in the denial of
enrollment.
OMB Control Number 0703-0080
Page 1 of 10
End of Block: Privacy Act Statement
Start of Block: Landing page
Thank you for your interest in this study. This screening asks questions that will only be used to
determine if you are eligible for study participation. If you are eligible, someone from the
research team will contact you about study participation.
Please indicate if you would like to proceed with the screening process:
o I do not agree (4)
o I agree (5)
OMB Control Number 0703-0080
Skip To: End of Survey If Thank you for your interest in this study. This screening asks questions that will
only be used t... = I do not agree
End of Block: Landing page
Start of Block: Demographics
What is your age (in years)?
(1)
▼ 18 (1) ... Other (8)
Page 2 of 10
Understanding that gender identity can be complex, which ONE category best describes your
GENDER IDENTITY now?
o Man (1)
o Woman (2)
o Prefer not to answer (3)
Are you currently an active duty sailor?
o Yes (1)
o No (2)
OMB Control Number 0703-0080
End of Block: Demographics
Start of Block: AUDIT-C
How often did you have a drink containing alcohol in the past year?
o Never (0)
o Monthly or less (1)
o 2 to 4 times a month (2)
o 2 to 3 times a week (3)
o 4 or more times a week (4)
Page 3 of 10
How many drinks containing alcohol did you have on a typical day when you were drinking in
the past year?
o None, I do not drink (0)
o 1 or 2 drinks (0)
o 3 or 4 drinks (1)
o 5 or 6 drinks (2)
o 7 or 9 drinks (3)
o 10 or more drinks (4)
How often did you have six or more drinks on one occasion in the past year?
o Never (0)
o Less than monthly (1)
o Monthly (2)
o Weekly (3)
o Daily or almost daily (4)
OMB Control Number 0703-0080
End of Block: AUDIT-C
Start of Block: contact form-low male
Thank you for taking the time to answer these questions. According to your responses you may
be eligible to participate in the study.
To assist in scheduling, please provide the contact information below.
Page 4 of 10
What is your first and last name?
________________________________________________________________
What is your rank?
(1)
▼ E1 (1) ... O10 (25)
Email:
________________________________________________________________
Cell phone number:
________________________________________________________________
What is your current country of residence?
________________________________________________________________
What is your time zone?
(4)
▼ A (Alpha Time Zone) - Military (UTC +1) (1) ... Z (Zulu Time Zone) - Military (UTC+0) (239)
Page 5 of 10
Can we text you?
o Yes (1)
o No (2)
OMB Control Number 0703-0080
End of Block: contact form-low male
Start of Block: contact form-high male
Thank you for taking the time to answer these questions. According to your responses you may
be eligible to participate in the study.
To assist in scheduling, please provide the contact information below.
What is your first and last name?
________________________________________________________________
What is your rank?
(1)
▼ E1 (1) ... O10 (25)
Email:
________________________________________________________________
Page 6 of 10
Cell phone number:
________________________________________________________________
What is your current country of residence?
________________________________________________________________
What is your time zone?
(4)
▼ A (Alpha Time Zone) - Military (UTC +1) (1) ... Z (Zulu Time Zone) - Military (UTC+0) (239)
Can we text you?
o Yes (1)
o No (2)
OMB Control Number 0703-0080
End of Block: contact form-high male
Start of Block: contact form-high female
Thank you for taking the time to answer these questions. According to your responses you may
be eligible to participate in the study.
To assist in scheduling, please provide the contact information below.
Page 7 of 10
What is your first and last name?
________________________________________________________________
What is your rank?
(1)
▼ E1 (1) ... O10 (25)
Email:
________________________________________________________________
Cell phone number:
________________________________________________________________
What is your current country of residence?
________________________________________________________________
What is your time zone?
(4)
▼ A (Alpha Time Zone) - Military (UTC +1) (1) ... Z (Zulu Time Zone) - Military (UTC+0) (239)
Page 8 of 10
Can we text you?
o Yes (1)
o No (2)
OMB Control Number 0703-0080
End of Block: contact form-high female
Start of Block: contact form-low female
Thank you for taking the time to answer these questions. According to your responses you may
be eligible to participate in the study.
To assist in scheduling, please provide the contact information below.
What is your first and last name?
________________________________________________________________
What is your rank?
(1)
▼ E1 (1) ... O10 (25)
Email:
________________________________________________________________
Page 9 of 10
Cell phone number:
________________________________________________________________
What is your current country of residence?
________________________________________________________________
What is your time zone?
(4)
▼ A (Alpha Time Zone) - Military (UTC +1) (1) ... Z (Zulu Time Zone) - Military (UTC+0) (239)
Can we text you?
o Yes (1)
o No (2)
OMB Control Number 0703-0080
End of Block: contact form-low female
Start of Block: Ineligible
Thank you for taking the time to answer these questions. According to your responses, you
are not eligible to participate in this study.
OMB Control Number 0703-0080
End of Block: Ineligible
Page 10 of 10
| File Type | application/pdf |
| File Title | Microsoft Word - Change_Sailors_-_Interview_Screen-7.docx |
| File Modified | 2022-08-03 |
| File Created | 2022-04-12 |