AppxB Eligibility Screener

Appendix B Eligibility Screener Form SAMPLE

Form Approved

OMB No. 0923-0051

Exp XX/XX.XXXX

Eligibility Screener Form

Date _____________ Start time _____________ End time ______________

Participant Name: ____________________________________________________

Eligibility Screener Form

Indicate that the person is English speaking:

• Yes [Continue below]

• No [If survey is available in Spanish or there are translations services available offer this options]

Hello, I’d like to find out if you are eligible to take part in the [requesting jurisdiction] investigation of the recent [type of incident].

I would like to begin by showing you a map of the areas affected by the incident on [start date and time]. The affected areas are [highlighted/circled/etc.]. From now on, I will refer to the [type of incident] on [start date and time] as “the incident.”

[SHOW MAP]

Were you in this area of the incident at any time between [start date and time] and [end date and time]?

• Yes, Eligible: Now that we know you were in the area during the incident, you are eligible to participate in this investigation and I would like to ask you some more questions. Do you agree, to participate in our survey

• Yes, I’d like to participate. [Go to consent form]

• No, [END SURVEY]

• No NOT Eligible: Thank you for your time. At this time you are not eligible to participate in this investigation. [END SURVEY]