Portable Electric Heaters |
CPSC |
762 CPSC-PEH Study
Draft OMB 1.0
[TEXT IN BRACKETS ARE PROGRAMMING INSTRUCTIONS, LOGIC, OR IDENTIFICATION OF TREND QUESTIONS]
Thank you for your interest! EurekaFacts is a social science research firm conducting an important study on behalf of the U.S. Consumer Product Safety Commission (CPSC) to develop safety communications related to household products and fire safety.
EurekaFacts will conduct several focus group sessions of 5-8 participants that will take up to 90 minutes. The sessions will be conducted remotely via a video online conferencing platform and, in some sessions, participants will be asked to answer some questions individually first. The focus group will be audio and video recorded. All of the information provided may be used only for statistical purposes and may not be disclosed, or used, in identifiable form for any other purpose except as required by law (20 U.S.C. §9573 and 6 U.S.C. §151). OMB Control No.: XXXX-XXXX
If you qualify and participate in the focus group session, you will receive a $100 e-gift card from a major credit card company to thank you for your time and effort.
To ensure that our focus group participants are a broad mix of individuals, please answer the following brief questionnaire to check your eligibility and availability. All questions are required and should only take about 5-10 minutes of your time.
[MODULE 1: PARTICIPANT SCREENER]
[ASK ALL: REQUIRED]
S.0 Are you interested in participating in an online 90-minute focus group session?
Yes
No [GO TO TERMINATE]
[ASK ALL: REQUIRED]
S.1 Are you 18 years of age or older?
Yes, I am 18 years of age or older
No, I am under 18 years of age [GO TO TERMINATE]
[ASK ALL: REQUIRED]
S.2 Do you own any of the following items in your house? Please select all that apply.
Emergency escape ladder
Smoke detectors
Electric water kettle
Security alarm system
Portable electric space heater (not gas, kerosene, or propane) [IF NOT SELECTED GO TO TERMINATE] [IF SELECTED GO TO S.4]
Fire extinguisher
I do not have any of these [GO TO TERMINATE]
[ASK ALL: REQUIRED]
S.3 When did you purchase or acquire your portable electric space heater?
[DROP DOWN LIST]
This year
2022
2021
2020
2019
2018
2017
2016
2015 or older [GO TO TERMINATE]
Do not remember [GO TO TERMINATE]
[ASK ALL: REQUIRED]
S.4 When was the last time you used your portable electric heater (PEH)?
Within the last 12 months
Within the last 13-24 months
Between 2 and 5 years [GO TO TERMINATE]
More than 5 years ago [GO TO TERMINATE]
Never used or do not recall when last used [GO TO TERMINATE]
[ASK ALL: REQUIRED]
S.5 To participate in the session, we must receive a consent form before the focus group. We will provide you with a digital consent form that does not require downloading or printing. Do you agree to submit the completed consent form to participate?
Yes, I agree
No, I do not agree [GO TO TERMINATE]
[BRANCHING (TERMINATION POINTS TO BE EVALUATED AFTER S.5.): IF S.2. ≠ 5 OR IF S.2. = 7 GO TO TERMINATE; IF S.3. = 9 GO TO TERMINATE; IF S.4. = 3 OR 4 GO TO TERMINATE; IF S.5. = 2 GO TO TERMINATE]
[MODULE 2: PARTICIPANT DEMOGRAPHICS]
[ASK ALL: REQUIRED]
Q.1 What is your gender?
Female
Male
Non-binary
Prefer to self-describe: _______________
Prefer not to answer
[ASK ALL: REQUIRED]
Q.2 What is your age?
18-24
25-34
35-44
45-54
55-64
65-74
75 or older
[ASK ALL: REQUIRED]
Q.3 Are you of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino, or Spanish origin
ASK IF Q.3 > 1]
Q.3A Focus Groups will be held in either English or in a mix of Spanish and English. Which language would you prefer to participate in?
English only
A mix of Spanish and English
[ASK ALL: REQUIRED]
Q.4 Which race do you identify with? Select all that apply.
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Another race (please specify) __________
[ASK ALL: REQUIRED]
Q.5 What is the highest level of education you have completed or the highest degree you have received?
Less than high school
High school graduate or GED equivalent
Trade or vocational school degree
Some college, no degree
Two-year associate degree from a college or university
Some postgraduate or professional schooling, no postgraduate degree
Postgraduate or professional degree
[ASK ALL: REQUIRED]
Q.6 How many people, including yourself, live in your household? (Includes people (adults and children) who think of your household as their primary residence, including those temporarily away on business, vacation, in a hospital, or away at school.)
[DROP DOWN LIST: “1” to “8 or more”]
[ASK IF Q.6 >1: REQUIRED]
Q.7 Are you the parent or guardian of any children under the age of 18 living within your household?
Yes
No
[ASK IF Q.6 >1: REQUIRED]
Q.8 Including yourself, how many people live in your household that are…
[LIST ITEMS]
[RESPONSE OPTIONS]
[DROP DOWN LIST FOR EACH ITEM 1-4: “0” to “8 or more”]
[ASK ALL: REQUIRED]
Q.9 Last year, in 2022, what was your total household income from all sources, approximately?
Less than $20,000
$20,000 to $29,999
$30,000 to $39,000
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $69,999
$70,000 to $79,999
$80,000 to $89,999
$90,000 to $99,999
$100,000 or more
Prefer not to answer
[ASK ALL: REQUIRED]
Q.10 What state do you live in currently?
[DROP DOWN LIST: 50 STATES INCLUDING D.C.]
[ASK ALL: REQUIRED]
Q.11 What city/town do you live in currently?
[SHORT ANSWER RESPONSE]
[ASK ALL: REQUIRED]
Q.12 What is the ZIP code where you primarily live?
[SHORT ANSWER RESPONSE]
Q.13 Which best describes your home?
Single-family detached home
Townhome or row house multiple family attached home
Apartment or condo
Mobile or trailer home
Boat, RV, or Van
Other _________________
[ASK ALL: REQUIRED]
Q.14 Tell us about the last time you were concerned about household appliances (e.g., refrigerator, oven, microwave, etc.) and fire safety in your home. What were some actions you took? (Please write at least one sentence.)
[LONG ANSWER RESPONSE]
[MODULE 3: SCHEDULING]
[If no ‘terminated’ responses selected, respondents continue with scheduling and contact information.]
[READ
ALL:] Thank you for answering these questions. If you are selected
as a focus group discussion participant, you will receive an e-mail
and/or a call from us to confirm your participation and to be
informed of the venue/platform, date, and time of the session.
[ASK ALL: REQUIRED]
B1. Please provide us with your preferred contact information. If selected, we will use this to contact you to schedule a session.
First Name ______________
Last Name _______________
Email Address _____________
Best Phone Number ____________
Alternative Phone Number (optional) [NOT REQUIRED] ____________
[ASK ALL: REQUIRED]
B2. May we contact you via SMS text messages for scheduling, confirmations, and reminders? (We will not sell your information. This permission is only for this project.)
Yes
No
[ASK ALL: REQUIRED]
B3. To help us schedule the focus group at a time that is convenient for you, please provide your general availability between <INSERT DATES>.
Once again, the focus groups will be held remotely online and not in-person. Select all that apply (Each line must have an entry. If not available for that day, please select ‘Not available’).
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Afternoon (12PM–4PM) |
NOT AVAILABLE [Exclusive] |
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Monday |
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Tuesday |
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Wednesday |
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Thursday |
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Friday |
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Saturday |
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[ASK ALL: REQUIRED]
B4. Time Zone:__________ [DROP DOWN LIST]
Eastern Standard Time (GMT-5)
Central Standard Time (GMT-6)
Mountain Standard Time (GMT-7) Observe Daylight Saving Time
Mountain Standard Time (GMT-7) Do not observe Daylight Saving Time
Pacific Standard Time (GMT-8)
Alaska Standard Time (GMT-9)
Hawaii-Aleutian Standard Time (GMT-10)
[ASK ALL: NOT REQUIRED]
B5. Feel free to provide any other comments about your availability between <DATES> or your preferred time to join the focus group.
[SHORT ANSWER RESPONSE]
Termination Language: Thank you for your expressed interest.
Based on the requirements of this study, we are not able to include
you in the focus group at this time.
Requirement
Language: Please answer this question before continuing. /
Please select at least one choice for this question.
Closing language: Thank you for your interest and
completing this questionnaire. If you are eligible, a staff member
will contact you by email or phone call in the next few weeks.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Motor Vehicle Injury Prevention Profiles |
| Author | Alison Wurzel |
| File Modified | 0000-00-00 |
| File Created | 2023-07-29 |