Form 0920-23AX Online Screener English

Attachment 20. Online Screener – English

CDC Women’s Health Study

Thank you for your interest in this study!

EurekaFacts, an independent research company, has been contracted by the Centers for Disease Control and Prevention (CDC) for an important study. We are looking to hear from Spanish-speaking Hispanic/Latina women about women’s health and the role that culture plays in their health choices. Conversation sessions with Spanish-speaking Hispanic/Latina women will be held both online and in-person. We would like to hear your honest feelings, thoughts, and experiences during a safe, non-judgmental, and respectful group conversation. Participation is voluntary. Your responses will be kept confidential—we will not share personal information or responses with anyone outside the research team.

• Each conversation session will be about 90 minutes.

• Conversation sessions will either be online OR in-person.

• At the end of a session, each participant will receive a $75 gift card* for their time and effort (*e-gift card for those who participate in a virtual focus group and physical gift card for those who participate in an in-person focus group).

To see if you are eligible for this study, please answer the following questions. It should take about 10 minutes to fill out. Please keep in mind that we will not share your answers with anyone. Click the arrow (à) to continue.

[[à button]]

Privacy Act Statement

The information you are being asked to provide is subject to the Privacy Act and is covered by the System of Records Notice (SORN) 09-20-0136, “Epidemiologic Studies and Surveillance of Disease Problems”.  Providing this information is voluntary.  The principal purposes for which CDC will use the information that you provide for the CDC Women’s Health Study are to (1) understand folic acid and fortified food awareness, as well as food and supplement use practices, (2) develop new messaging and communication products to improve knowledge, awareness, and practices, and (3) inform future intervention activities to prevent neural tube defects among Hispanic/Latina women of reproductive age.  The information that you provide for the KAPs Women’s Health Study will only be used to conduct the project. The information you provide will be maintained in a Privacy Act system of records and will be used and may be disclosed for the purposes and routine uses as described and published in the aforementioned SORN which can be found at: www.hhhs.gov/foia/privacy/sorns/09200136/index.html

[Required: All]

1. Would you be interested in participating in a conversation session ...?

1. In-person

2. Online

3. Either in-person or online

4. I am not interested in participating in any conversation session [THANK FOR TIME]

[Required: Show if Q1= 2 or 3]

2. Can you access the internet and a computer (laptop, tablet) with speakers, a microphone, and a webcam? (Smartphones may be difficult to use for this study. We will be sharing material on the screen)

1. Yes

2. No [IF Q1= 2 THANK AND DISMISS, CONTINUE IF Q1=3 (disqualify for online)]

[Required: All]

3. What sex were you assigned at birth, on your original birth certificate?

1. Male [THANK AND DISMISS]

2. Female

3. I don’t know [THANK AND DISMISS]

[Required: All]

4. Have you been pregnant before?

1. Yes

2. No

[Required: All]

5. What is your current pregnancy status?

1. Not currently pregnant, but would like to get pregnant in the next year

2. Not currently pregnant and does not want to get pregnant in the next year

3. Not currently pregnant but recently had a child (within the past 2 years)

4. Currently pregnant [THANK AND DISMISS]

5. Cannot become pregnant [THANK AND DISMISS]

[Required: All]

6. How old are you?

[OPEN-RESPONSE:] __________ [Must be 18 to 44 years, otherwise THANK AND DISMISS.]

[Required: All]

7. Ethnicity:

1. Hispanic or Latino

2. Not Hispanic or Latino [THANK AND DISMISS]

3. Prefer Not to Answer [THANK AND DISMISS]

[Required: All]

8. What is your family’s country of origin/national background? (Select all that apply)

1. Argentina

2. Belize

3. Bolivia

4. Brazil

5. Chile

6. Colombia

7. Costa Rica

8. Cuba

9. Dominican Republic

10. Ecuador

11. El Salvador

12. Guatemala

13. Guyana

14. Honduras

15. Mexico

16. Nicaragua

17. Panama

18. Paraguay

19. Peru

20. Puerto Rico

21. United States

22. Uruguay

23. Venezuela

24. Other: _____

[Required: All]

9. Race (select all that apply):

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Native Hawaiian or Other Pacific Islander

5. White

6. Prefer Not to Answer [Deselect other responses if selected]

[Required: All]

10. What language(s) do you usually speak at home?

1. Only Spanish 

2. Mostly Spanish 

3. Spanish and English equally 

4. Mostly English 

5. Only English

[Required: All]

11. In what country or territory were you born?

1. In the United States

2. In Puerto Rico

3. Outside of the United States or Puerto Rico

[Required: Show if Q11=3]

12. From the time that you first moved to the United States to today, about how many years have you lived in the United States (50 states and Washington, D.C.)?

[OPEN-ENDED NUMERICAL VALUE (0-60)] __________

[BRANCHING: {IF Q10=4 OR 5 AND Q11=1 à DISMISS}]

[Required: All] [Randomize]

13. Do you consume any of the following at least three times a week? (Select all that apply.)

1. Corn masa flour (nixtamalized corn flour) (like tamales, tortillas, pupusas, gorditas, empanadas, atoles, and sopes) [ALL PARTICIPANTS MUST SELECT THIS OPTION TO BE ELIGIBLE, if not selected THANK AND DISMISS]

2. Breads (like whole wheat and white bread)

3. Breakfast cereals

4. Beans or lentils

5. Rice

6. Vegetables (like broccoli and celery)

7. Fruit (like strawberries or bananas)

8. Cheese

9. Milk

10. Vitamins/Supplements

[Required: All]

14. What state do you live in?

[Drop-down list of states:] _________

[Show if Q1=1: Required]

15. What is your zip code?

[OPEN-ENDED (ZIP CODE):] __________

[Required: All]

16. Do you live in…?

1. An urban or city area

2. A suburban area next to a city

3. A small town

4. A rural area like the countryside or on a farm

[Required: All]

17. What is the highest level of education you have completed?

1. Some high school or less

2. High school diploma or GED

3. Currently enrolled in college or university, or some college but no degree

4. Trade/technical/vocational school

5. Associate degree

6. Bachelor’s degree

7. Master’s degree or higher

SCHEDULING

Thank you again for your interest. EurekaFacts will be holding conversation sessions IN SPANISH only between [DATES]. What days and timeframes are you free for a 90-minute conversation group? SELECT ALL THAT APPLY

	Morning (8:00 – 11:30 AM)	Afternoon (12:00 – 4:30 PM)	Evening (5:00 – 8:30 PM)	Not Available [Exclusive]
Monday	☐	☐	☐	☐
Tuesday	☐	☐	☐	☐
Wednesday	☐	☐	☐	☐
Thursday	☐	☐	☐	☐
Friday	☐	☐	☐	☐
Saturday	☐	☐	☐	☐

TIMEZONE: [DROPDOWN LIST]

1. Alaska Standard Time (GMT-9)

2. Central Standard Time (GMT-6)

3. Eastern Standard Time (GMT-5)

4. Hawaii-Aleutian Standard Time (GMT-10)

5. Mountain Standard Time (GMT-7) Observes Daylight Saving Time

6. Mountain Standard Time (GMT-7) Does not observe Daylight Saving Time

7. Pacific Standard Time (GMT-8)

CONTACT INFORMATION

EurekaFacts will reach out to you via email if you are selected for one of our conversation sessions. If the conversation session is scheduled far enough in the future, EurekaFacts will reach out again to remind you as the date approaches. Please provide your preferred contact information. (If no email enter [email protected])

First Name: ___________

Last Name: ___________

Email: ___________

Best Phone Number: ___________

May we contact you via text messages for scheduling, confirmations, and reminders? (We will not sell your information. This permission is only for this study.)

1. Yes

2. No

[Closing Language: Thank you for your time. Have a great day!]

[Termination Language: Thank you for your time. Unfortunately, you do not qualify for this study at this time. Have a great day!]

[Completion Language: Thank you for your time. Your responses have been submitted. EurekaFacts will reach out to you directly if you are selected for a session. Have a great day!]