APPENDIX 5_Sample Participant Screener

OMB Control No.: 0584-0523
Expiration Date: xx/xx/xxxx

APPENDIX 10

Sample Participant Screener

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection unless it displays a valid OMB Control number. The valid OMB number for this
collection is 0584-0523. The time required for this information collection is estimated to
average 15 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.

CONSUMER MESSAGE TESTING for the DIETARY
GUIDELINES for AMERICANS and MYPLATE
Participant Screening Questionnaire
[Recruit 12 respondents to obtain 10 participants for each group.]
Hello, my name is _____with______. We are conducting a market research survey and I would
like to ask you a few questions about nutrition and diet. I’m not trying to sell you anything.
1.

Do you, or does anyone in your household, work in any of the following types of
industries? [Record each “YES” response.]
Advertising .....................................................(
Market research/Marketing ........................... (
Healthcare ..................................................... (
Nutrition or Fitness ....................................... (
Pharmaceuticals ............................................ (

2.

)
)
) Terminate if “YES” to any
)
)

Have you participated in a market research focus group in the past six months?
No .................................................................. ( ) Continue
Yes ............................................................... ( ) Terminate
Don’t know/Refused .................................... ( ) Terminate

3.

What is your current age? ____ [Specify]
Under 20......................................................... ( ) Terminate
20 to 49 ......................................................... ( ) Recruit for “Younger” Group
(unless otherwise disqualified)
50 to 79 ......................................................... ( ) Recruit for “Older” Group
(unless otherwise disqualified)
Older than 79 ................................................ ( ) Terminate

OMB Control No.: 0584-0523
Expiration Date: xx/xx/xxxx
4.

Record Gender [Do not ask unless unable to tell.]
Female ........................................................... ( ) Continue
Male ............................................................. ( ) Continue

5.

Does anyone in your household, including yourself, have any of the following conditions
that might affect the type or amount of food served to members of the household?
On a medically prescribed diet ..................... ( )
Allergic to wheat products or milk .............. ( ) Terminate if “YES” to any
On medication or undergoing treatment for
a health condition such as heart disease,
cancer, or diabetes ........................................ ( )

6.

Do you consider yourself an “expert” in nutrition?
No .................................................................. ( ) Continue
Yes ............................................................... ( ) Terminate
Don’t know/Refused .................................... ( ) Terminate

7.

What is your race or ethnicity?
[Read list and record one or more answer.]
American Indian or Alaska Native ................ (
Asian ............................................................. (
Black or African American ........................... (
Hispanic or Latino ......................................... (
Native Hawaiian or Other Pacific Islander ... (
White ............................................................. (

8.

)
)
)
)
)
)

[Obtain a mix that is
roughly proportional to
the local population.]

What is your marital status?
Married .......................................................... ( )
Single, never married .................................... ( ) Recruit a mix
Separated/divorced/widowed ........................ ( )

9.

Would you say your total annual household income is:
Under $25,000................................................ (
$25,000 to $50,000 ....................................... (
$50,000 to $75,000 ....................................... (
Over $75,000 ................................................. (

10.

)
)
)
)

Recruit a mix

What is the highest level of education you have completed? [Do not read list]
2

OMB Control No.: 0584-0523
Expiration Date: xx/xx/xxxx

Some high school .......................................... (
High school graduate, some college,
vocational or technical school ....................... (
College graduate ........................................... (
Post college ................................................... (
11.

)
)
)
)

Recruit a mix

In your opinion, what is the biggest health problem in America today, and why?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
[After recording respondent’s answer, determine whether or not you feel this
respondent would be useful in the group. Did he or she:
Give a full and complete answer?
Speak clearly, and without long pauses?
Answer enthusiastically?
It is most important that the respondent be articulate! If not, terminate.]

12.

I would like to invite you to participate in a focus group discussion that will be held at
our facility. The session will last approximately two hours.
During the focus group, you will have an opportunity to share your thoughts and
opinions with other adults from your area. You will not be asked to buy any
products, nor will you be contacted at a later date.
As a token of appreciation, you will receive $___ in cash at the conclusion of the session.
[SPECIFIC AMOUNT WILL DEPEND ON LOCATION AND FACILITY] Would you
be willing to participate?
Yes ................................................................ ( ) SCHEDULE
No ................................................................. ( ) THANK & END
GROUP TYPE

DAY

TIME

_________________________

_______________

_______

I will call you to remind you of this appointment. However, if for some reason you are
unable to attend, please call me at (TELEPHONE NUMBER) so that I can find a
replacement for you.
Thank you.

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