2 Screening Questions

OMB No. 0915-0212 Exp. Date 07/3/2021

Screener

HRSA Focus Groups Related to Organ Donation

Summary of recruiting specifications

Mix of men and women

Support organ donation

Are not registered organ donors

Mix of educational levels

Do not work in the field of market research or related to organ donation

Have not been in a focus group in the past six months

Groups based on race and ethnicity

(RECRUIT 6 PER GROUP)

1. Thank you for your interest in this project. We are recruiting people to attend a focus group that will take place online from [time] on [date]. All participants will be paid $100 for their time. If you are eligible for the study, would you be interested in participating?

1. Yes

2. No (THANK AND END)

Note whether respondent is male or female and recruit a mix.

1. Male

2. Female

2. To begin, thinking about organ donation, do you do you strongly support, support, oppose, or strongly oppose organ donation?

1. Strongly support

2. Support

3. Oppose (THANK AND END)

4. Strongly Oppose (THANK AND END)

3. Are you a registered organ donor, either by registering on your driver’s license, a donor card, or an organ donor registry?

1. Yes (THANK AND END)

2. No

4. Now, I need to ask you some basic information. Which category best describes your age?

1. Under 21 (THANK AND END)

2. 21–35

3. 36–49

4. 50–65

5. 66 or older

Recruit a mix of ages.

5. What is the highest grade you have completed in school? [READ LIST IF NECESSARY]

1. 8th grade or less

2. Some high school (grades 9, 10, or 11)

3. High school graduate or GED (High school equivalency)

4. Some college/2-year college/technical school/associate degree

5. College graduate

6. Some graduate school/post-graduate degree

Recruit a mix of education levels.

6. We want to make sure we represent different ethnic and racial groups in our study. Would you describe yourself as [SELECT ALL THAT APPLY]:

1. White (THANK AND END)

2. Black or African American

3. Asian

4. Native Hawaiian or Other Pacific Islander

5. Hispanic or Latino/Latina

6. American Indian or Alaskan Native

Some sessions will be single ethnicity. Others will be mixed.

7. What is your present occupation? ___________________

1. Related to organ donation (THANK AND END)

2. Related to market research (THANK AND END)

3. All others

8. Have you ever participated in a focus group or been paid to be part of a discussion group?

1. Yes

2. No (SKIP TO Q10)

9. How recently did you participate in this focus group or discussion group?

1. Within the past six months (THANK AND END)

2. More than six months ago

10. Thank you. We are conducting an informal group discussion on issues related to organ donation, and your views would be valuable in helping us better understand this issue. The discussion will take place online on [date] at [time]. The discussion will last 90 minutes, and there will be no attempt to sell you anything or convince you to register as a donor. We are

simply interested in your opinions. We will pay you $100 as a way of thanking you for participating. Would you be interested in attending?

1. No (THANK AND END)

2. Yes

11. Great! We would like to send you a message to confirm your participation in this study, and we will also call you the day before to remind you. Can you please provide me with your …?

NAME:

E-MAIL ADDRESS:

PHONE NO:

** Double check spelling of name and read back phone and e-mail to confirm ***

12. It is very important that you let us know right away if you will not be able to attend this discussion so that we may have time to find a replacement. Will you call us at [phone] if for some reason you cannot attend? [WAIT FOR AN ANSWER]

Thank you for your time and for agreeing to participate. We look forward to having you participate!

1

The purpose of this collection is to obtain feedback from customers and potential customers related to the HRSA Division of Transplantation’s (DoT) outreach materials on organ donation and transplantation for minority audiences. The results of this collection will enable HRSA DoT to appropriately address the unique information needs of minorities in its communication materials and outreach efforts. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0212 and it is valid until 07/03/2021. This information collection is voluntary. All information obtained will be used by HRSA DoT, and will not be shared with the public. Public reporting burden for this collection of information is estimated to average 1.75 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].