Attachment 3_Screening Instrument_KAP Surveys

Attachment 1 Flesch-Kincaid Grade Level: 7.9

Lyme and Other Tickborne Diseases Prevention Study

Knowledge, Attitudes, and Practices Survey

Screening Instrument

INITIAL CONTACT

Hello, my name is (insert name). I am calling on behalf of the (insert site specific EIP title) regarding a Lyme disease research study that is being conducted in conjunction with the Centers for Disease Control and Prevention.

May I please speak with (insert contact name)?

 Yes, speaking. (Go to Introduction)

 Yes, but not home now/busy.

When would be a better time to reach him/her?

Thank you for your time today. (STOP HERE) (In database, add note to log for introductory survey of day/time)

 No. No one in house by that name.

Thank you for your time today. (STOP HERE)

 Does not speak English. (exclusion criteria)

We can only interview someone who speaks English. Thank you for your time today. (STOP HERE)

INTRODUCTION

[When potential enrollee comes to phone]

We are working with the Centers for Disease Control and Prevention and your state health department to try to better understand how to prevent tickborne diseases. I would like to provide you with information about the study and answer any questions you may have. Is now a good time to talk?

 Yes. (Go to Study Description)

 No.

If this is a bad time, I could contact you at a time that may be more convenient for you. Is this possible?

 Yes.

Thank you for your time and interest in this study. (STOP HERE) (In database, record day and time to call back in log for introductory survey and add follow-up date below introductory survey checkbox.)

 No.

Sorry to have inconvenienced you. Thank you for your time today. (STOP HERE)

STUDY DESCRIPTION

Through this study, we hope to learn more about what methods people use or would be willing to use to prevent Lyme disease and other tickborne diseases. The purpose of this study is to better understand how to stop people from getting Lyme disease and other tickborne diseases. We are asking you to be in this study because you live in an area where tickborne diseases occur. If you agree to be in the study, we will ask you to complete short phone-based, in-person, or online study surveys that ask about your activities when you spend time in your yard, your exposure to ticks, what you use to prevent tick bites, if you have been ill with a tickborne disease(s) and your experience with this illness. These surveys will take about 5 to 10 minutes to complete, depending upon the survey. Study participation is voluntary. You are free to join the study or decide not to join. You may also leave the study at any time, for any reason. Are you still interested in participating in this study?

 Yes.

Great, I will now proceed to ask you a few questions to see if you are eligible to participate in the study. (Go to Study Eligibility)

 No.

If you change your mind and would like to participate in this study, please call/email your State Health Department/[Local EIP Contact] at (xxx) xxx-xxxx / [email address] or Sarah Hook, study coordinator (CDC), at (xxx) xxx-xxxx / [email protected]. Thank you for your time today. (STOP HERE)

STUDY ELIGIBILITY

Before we proceed further I would like to make sure that you meet the eligibility requirements for the study.

ELIGIBILITY QUESTIONS
#1: Are you at least 18 years of age?	 Yes [ELIGIBLE GO TO NEXT QUESTION]	 No [INELIGIBLE STOP] I’m sorry, but we are only enrolling people who are at least 18 years of age.	 Don’t Know [INELIGIBLE STOP] I’m sorry, but we are only enrolling people who are at least 18 years of age.
#2: Are you living in a free-standing home with a surrounding yard?	 Yes [ELIGIBLE GO TO NEXT QUESTION]	 No [INELIGIBLE STOP] I’m sorry, but we are only enrolling people with freestanding homes which have yards.	 Don’t Know [INELIGIBLE STOP] I’m sorry, but we are only enrolling people with freestanding homes which have yards.
#3: Are you living in (insert target community/ communities)?	 Yes [ELIGIBLE GO TO NEXT QUESTION]	 No [INELIGIBLE STOP] I’m sorry, but we are only enrolling households in (insert target community/ communities).	 Don’t Know [INELIGIBLE STOP] I’m sorry, but we are only enrolling households in (insert target community/ communities).
#4: Do you make decisions about lawn treatment on behalf of your household?	 Yes [ELIGIBLE GO TO NEXT QUESTION]	 No [INELIGIBLE STOP] Could I please speak with the household member who can provide consent? [GO TO INTRODUCTION]	 Don’t Know [INELIGIBLE STOP] Could I please speak with the household member who can provide consent? [GO TO INTRODUCTION]
#6: Do you primarily reside at this residence during the summer (e.g., May-August), such that this is your permanent residence or summer home?	 Yes [ELIGIBLE GO TO NEXT QUESTION]	 No [INELIGIBLE STOP] I’m sorry, but we are only enrolling households whose occupants primarily reside at this study location during the summer.	 Don’t Know [INELIGIBLE STOP] I’m sorry, but we are only enrolling households whose occupants primarily reside at this study location during the summer.
#7: Is your total property greater than ½ acre in size?	 Yes [ELIGIBLE GO TO NEXT QUESTION]	 No [INELIGIBLE STOP] I’m sorry, but we are only enrolling households who have properties between ½ acres and 5 acres in size.	 Don’t Know [INELIGIBLE STOP] I’m sorry, but we are only enrolling households who have properties between ½ acres and 5 acres in size.

ELIGIBILITY CHECK:	 Yes [GO TO STUDY FORMS]	 No I’m sorry, but unfortunately you are not eligible for this study. Thank you for your time today and interest in this study.

STUDY FORMS

Good news, you are eligible to participate in this study. Since you are eligible for the study, we would like to mail you a few study documents for you to read and sign. We will include a self-addressed return stamped envelope for you to return the forms.

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