Attachment 12g – Stillbirth Phone Introduction and Informed Consent - English
The standardized telephone disposition codes and introductions are used for all SSP women and contain all required elements of informed consent. If Spanish translations will be used, each is translated into Spanish for those women who prefer to have the interview conducted in Spanish.
The disposition codes and the introductions are presented here; the main body contains the elements of informed consent. The PIDS system assigns a disposition code at each call attempt based on the information the interviewer provides. Scripts for special situations are programmed into the PIDS system based on information documented in state protocols. For a more detailed description of telephone interviewing procedures, refer to the SSP Telephone Interviewer Training Manual.
Complete the state-specific information in the telephone introductions below (state name, telephone number, etc.). No other changes shall be made to any introductions without prior approval from the CDC IRB (see Section 10.2 (Informed Consent) for more information).
If your state must report physical abuse to minors, this should be stated when speaking to minors. Add these introductions in this appendix; these will be identical to introductions 1-4 below, with the addition of the reporting requirement. Again, send these introductions to CDC for approval.
1. Telephone Disposition Codes (English)
<STATE> SSP TELEPHONE QUESTIONNAIRE
OFFICE USE ONLY SSP--__________________ Batch # __ __ Respondent project ID#: __ __ __ __ __ __ __ __ Phone No.______________________ |
CALL RECORD
CALL |
DATE MM/DD |
TIME hh mm |
am/pm (a)(p) |
RESULT CODE |
INTER- VIEWER |
APPOINTMENT/COMMENTS |
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START TIME : END TIME : Did Mom have a copy of the MAIL TIME TO CONDUCT INTERVIEW:__ __ (in minutes) QUESTIONNAIRE with her? [ ]yes [ ]no |
DIAL TELEPHONE NUMBER:
* NO ANSWER AFTER 5 RINGS: ENTER CODE N. TRY LATER.
* BUSY SIGNAL: ENTER CODE NB. TRY LATER.
* ANSWERING MACHINE: ENTER CODE A IF MESSAGE INDICATES THAT MOM IS AT THIS NUMBER AND NO MESSAGE IS LEFT ON MACHINE.
ENTER CODE AM IF MESSAGE INDICATES THAT
MOM IS AT THIS NUMBER AND MESSAGE IS
LEFT ON MACHINE.
ENTER CODE AW IF MESSAGE INDICATES THAT MOM IS NOT AT THIS NUMBER.
ENTER CODE AU IF MESSAGE IS UNCLEAR IF NUMBER IS CORRECT OR NOT. TRY LATER.
* PAGER: ENTER CODE P IF NO MESSAGE LEFT ON PAGER.
ENTER CODE PM IF MESSAGE LEFT ON PAGER.
* TELEPHONE COMPANY MESSAGE: ENTER CODE NDD. CALL BACK AFTER A FEW DAYS.
* TECHNICAL BLOCK ENTER CODE TB. TRY LATER.
IF ANSWERED, SAY: Hello, may I speak to (RESPONDENT NAME) ?
* YES/SPEAKING/THAT’S ME: CONTINUE WITH AINTRODUCTION@.
* IF THE PERSON ASKS WHY YOU
WANT TO SPEAK WITH THE
RESPONDENT:
SAY: I’m with the <STATE STILLBIRTH PROJECT NAME> project. We
would like her help in a survey we are doing about the health of women in <STATE>.
* RESPONDENT NOT AVAILABLE: ENTER CODE FB IF NO TIME SCHEDULED FOR CALL BACK.
ENTER CODE FBS IF TIME SCHEDULED FOR
CALL BACK.
ENTER CODE FM IF MESSAGE LEFT FOR MOM
TO CALL PRAMS OFFICE.
* RESPONDENT NOT AT THIS ASK HOW TO REACH RESPONDENT:
LOCATION/DOESN=T LIVE HERE: TRY TO GET TELEPHONE NUMBER
AND/OR ADDRESS—
RECORD UNDER COMMENTS. IF UNABLE TO GET ADDITIONAL CONTACT INFORMATION, ENTER CODE UW. YOU ARE DONE.
* REFUSAL/NO YOU MAY NOT: ENTER CODE FB IF NO TIME
SAY: I’m with the <STATE STILLBIRTH SCHEDULED FOR CALL BACK
PROJECT> .
project .We’re doing a survey about the
health of women in <STATE>. If this is ENTER CODE FBS IF TIME
not a good time to talk with SCHEDULED FOR CALL BACK.
(RESPONDENT=S NAME) , I can call
back later. ENTER CODE FM IF MESSAGE LEFT
FOR MOM TO CALL SSP OFFICE.
* 2ND REFUSAL/NO YOU MAY NOT: THANK RESPONDENT, ENTER CODE FR, NOTE REASON FOR REFUSAL.
* IF PERSON SPEAKS SPANISH: HAVE SPANISH-SPEAKING INTERVIEWER
CALL BACK, ENTER CODE FLS.
* IF RESPONDENT SPEAKS SPANISH: HAVE SPANISH-SPEAKING INTERVIEWER
CALL BACK, ENTER CODE MLS.
* IF PERSON DOESN’T SPEAK THANK PERSON, ENTER CODE FL.
ENGLISH OR SPANISH: YOU ARE DONE.
* IF RESPONDENT DOESN’T THANK RESPONDENT, ENTER CODE
SPEAK ENGLISH OR SPANISH: ML. YOU ARE DONE.
* IF PERSON OR RESPONDENT
HANGS UP ENTER CODE H. TRY LATER.
* WHEN RESPONDENT
COMES TO PHONE: CONTINUE WITH INTRODUCTION.
Introduction, Part 1.
Hello, I’m _________________, and I’m calling from the <STATE STILLBIRTH PROJECT NAME> project. <STATE STILLBIRTH PROJECT NAME> is a research project to learn more about why stillbirths happen to help prevent stillbirths in <STATE>.
On behalf of the <NAME OF HEALTH DEPARTMENT>, please accept our deepest sympathies to you and your family on the loss of your baby. This recent loss brings sadness and sorrow, and the death of any baby in our community affects us all.
Recently we mailed you a questionnaire. <Did you receive it?> Since we have not received it yet, I’d like to go ahead and do the survey with you now.
First, I’d like to make sure that I am talking with the right person. You are <mother’s name>__ and you were born in <mother’s year of birth>_. Is that correct?
à IF YES, CONTINUE WITH PART 2.
à IF NO:
What’s not correct?
à REMEMBER: DO NOT GIVE OUT ANY CONFIDENTIAL INFORMATION
FROM PRAMS UNTIL YOU KNOW YOU HAVE THE CORRECT PERSON.
à DESCRIBE SITUATION (MOM USES MAIDEN NAME, ETC.):
_______________________________________________________
_______________________________________________________
à IF THE MOM GIVES A YEAR OF BIRTH VERY DIFFERENT (+ 2 years) FROM WHAT YOU READ, ASK:
Have you recently lived at <street address>.?
à IF YOU ARE SATISFIED YOU HAVE THE CORRECT PERSON,
CONTINUE WITH PART 2.
à IF YOU DO NOT HAVE THE CORRECT PERSON:
I’m sorry. It seems we reached you by mistake. Thank you for your time.
OPTIONAL STATEMENT: < I have a brief introduction to read to you before we begin.>
Introduction, Part 2.
<STATE STILLBIRTH PROJECT NAME> is sponsored by the Centers for Disease Control and Prevention and the <NAME OF HEALTH DEPARTMENT>. The survey asks women who have had a stillbirth about things that may have happened before, during, and after a pregnancy that ended in a loss.
I am very sorry to hear about your loss and I would like to extend my deepest sympathies to you and your family. We are asking you to take part in an interview. Some of the questions I’ll ask you may be painful, but your answers are very important and by doing so you will be helping to improve the services and care for women and babies in the future. The information you give us will be used to help us find out why stillbirths happen and how to improve the care that families like yours receive.
We are asking all women in <YOUR STATE> who have had a stillbirth to answer these same questions. Your name was identified from recent vital records files.
Most questions are about your health and life before, during, and after your pregnancy that ended in a loss. It takes about 20-25 minutes to answer all questions. Some questions may be sensitive, such as questions about smoking or drinking during pregnancy.
You are free to do the survey or not. If you don’t want to participate at all, or if you don’t want to answer a particular question, that’s okay. There is no penalty or loss of benefits for not participating or answering all questions.
Your answers will be grouped with those from other women. Your name will not be on any reports from <STATE STILLBIRTH PROJECT NAME>. Your survey may be combined with information the health department has from other sources.
If you choose to do the survey, your answers will be kept private to the extent allowed by law and will be used only for research. What we learn from <STATE STILLBIRTH PROJECT NAME> will be used to plan programs to help prevent stillbirths in <YOUR STATE>.
If you have questions about <STATE STILLBIRTH PROJECT NAME>, please call <PROJECT COORDINATOR’S NAME>, <YOUR STATE> <STATE STILLBIRTH PROJECT NAME> Project Coordinator, at 1-800-<###-####>. If you have any questions about your rights in the project, please call <NAME OF A PERSON AT YOUR LOCAL IRB OFFICE> at <PHONE NUMBER>.
IF THE MOM IS IN JAIL, SAY: Your participation in the study will have no effect on parole.
Shall we begin?
IF NO, THEN SAY:
If this is not a good time to talk, I can call back later.
TRY TO SCHEDULE A CONVENIENT TIME TO INTERVIEW MOTHER.
1. THANK RESPONDENT.
2. ENTER APPROPRIATE CODE ON TELEPHONE INTERVIEW FORM:
ENTER MB IF NO TIME SCHEDULED FOR CALL BACK.
ENTER MBS IF TIME SCHEDULED FOR CALL BACK.
ENTER MWC IF MOM WILL CALL PRAMS OFFICE.
ENTER MWM IF MOM SAYS SHE WILL MAIL SURVEY.
(NOTE: TELL MOM THAT INTERVIEWER WILL CALL HER IN A FEW DAYS IF SURVEY HAS NOT BEEN RECEIVED IN THE MAIL.)
ENTER MWW IF MOM SAYS SHE WILL COMPLETE THE SURVEY ONLINE
(NOTE: TELL MOM THAT YOU WILL SEND HER AN EMAIL WITH THE
WEB SURVEY URL AND PASSCODE).
COLLECT THE MOTHER’S EMAIL ADDRESS: ____________________.
IF MOM WON’T PROVIDE EMAIL ADDRESS, OFFER OPTION TO SEND HER A LETTER THROUGH THE MAIL WITH THE WEB LINK AND PASSCODE.
TELL MOM AN INTERVIEWER WILL CALL HER IN A <X> DAYS IF THE SURVEY HAS NOT BEEN COMPLETED ONLINE.
IF MOTHER DOES NOT WANT TO DO INTERVIEW LATER, THEN:
1. THANK THE RESPONDENT
2. ENTER THE APPROPRIATE CODE ON TELEPHONE INTERVIEW FORM:
ENTER MR IF REFUSAL.
3. NOTE THE REASON FOR REFUSAL
IF YES, THEN SIGN BELOW AND BEGIN INTERVIEW.
DO NOT READ ALOUD THE FOLLOWING: THIS IS TO CERTIFY THAT I HAVE READ THE ENTIRE INTRODUCTION ABOVE TO THE RESPONDENT.
____________________________________________________________ (SIGNATURE OF INTERVIEWER) (DATE)
|
Introduction, Part 3.
Before we start, it might help for you to have a calendar to refer to. If you have the copy of the questionnaire we mailed to you, you may want to get it also and read along.
Please give me your answers as I read the questions to you.
GO TO PAGE 1 AND BEGIN THE QUESTIONNAIRE.
Hello, I’m _________________, and I’m calling from the <STATE PROJECT NAME> project. <STATE STILLBIRTH PROJECT NAME> is a research project to learn more about the health of women in <STATE>.
On behalf of the <NAME OF HEALTH DEPARTMENT>, please accept our deepest sympathies to you and your family on the loss of your baby. This recent loss brings sadness and sorrow, and the death of any baby in our community affects us all.
Recently you completed part of the <STATE STILLBIRTH PROJECT NAME> survey (online/on the phone).
Since you did not answer all of the questions, I’d like to go ahead and finish the survey with you now. <In appreciation for your help, we will send you a special gift.>
First, I’d like to make sure that I am talking with the right person. You are <woman’s name>__ and you were born in <woman’s year of birth>_. Is that correct?
à IF YES, CONTINUE.
Shall we begin?
IF NO, THEN SAY:
If this is not a good time to talk, I can call back later.
TRY TO SCHEDULE A CONVENIENT TIME TO INTERVIEW MOTHER.
1. THANK RESPONDENT.
2. ENTER APPROPRIATE CODE ON TELEPHONE INTERVIEW FORM:
ENTER MB IF NO TIME SCHEDULED FOR CALL BACK.
ENTER MBS IF TIME SCHEDULED FOR CALL BACK.
ENTER MWC IF MOM WILL CALL PRAMS OFFICE.
ENTER MWM IF MOM SAYS SHE WILL MAIL SURVEY.
(NOTE: TELL MOM THAT INTERVIEWER WILL CALL HER IN A FEW DAYS IF SURVEY HAS NOT BEEN RECEIVED IN THE MAIL.)
ENTER MWW IF MOM SAYS SHE WILL COMPLETE THE SURVEY ONLINE
(NOTE: TELL MOM THAT YOU WILL SEND HER AN EMAIL WITH THE
WEB SURVEY URL AND PASSCODE.)
COLLECT THE MOTHER’S EMAIL ADDRESS: ____________________.
IF MOM WON’T PROVIDE EMAIL ADDRESS, OFFER OPTION TO SEND HER A LETTER THROUGH THE MAIL WITH THE WEB LINK AND PASSCODE.
TELL MOM AN INTERVIEWER WILL CALL HER IN A <X> DAYS IF THE SURVEY HAS NOT BEEN COMPLETED ONLINE
GO TO PAGE WHERE RESPONDENT LEFT OFF AND CONTINUE THE QUESTIONNAIRE.
5. Telephone Introduction for Partial Survey (Spanish)
Hola, soy _________________, esta llamada es del proyecto <STATE STILLBIRTH PROJECT NAME>. <STATE STILLBIRTH PROJECT NAME> es un proyecto de investigación con el fin de aprender más acerca de la salud de las mujeres en el estado de <STATE>.
En nombre de <NAME OF HEALTH DEPARTMENT>, deseamos darles nuestro más sentido pésame a usted y a su familia por la pérdida de su bebé. Esta pérdida reciente trae tristeza y dolor, y la muerte de cada bebé en nuestra comunidad nos afecta a todos.
Recientemente usted completó una parte de la encuesta del <STATE STILLBIRTH PROJECT NAME> por Internet/por teléfono.
Como usted no respondió a todas las preguntas, quisiera finalizar la encuesta con usted ahora, si me lo permite.
Primero, quisiera asegurarme de que estoy hablando con la persona indicada. Usted es <woman’s name>__ y nació en <woman’s year of birth>. ¿Es esto correcto?
à SI RESPONDE SÍ, CONTINÚE
¿Comencemos?
SI CONTESTA QUE NO, ENTONCES DIGA:
Si éste no es un momento oportuno para hablar, puedo llamar más tarde.
TRATE DE PROGRAMAR UN HORARIO CONVENIENTE PARA ENTREVISTAR A LA MADRE.
1. AGRADEZCA A LA RESPONDIENTE.
2. INTRODUZCA EL CÓDIGO APROPIADO EN EL FORMULARIO DE ENTREVISTA TELEFÓNICA:
INTRODUZCA MB SI NO SE PROGRAMA NINGÚN HORARIO PARA VOLVER A LLAMAR.
INTRODUZCA MBS SI SE PROGRAMA UN HORARIO PARA VOLVER A LLAMAR.
INTRODUZCA MWC SI LA MADRE VA A LLAMAR A LA OFICINA DE PRAMS.
INTRODUZCA MWM SI LA MADRE DICE QUE ENVIARÁ LA ENCUESTA POR CORREO.
(NOTA: DÍGALE A LA MADRE QUE UN ENTREVISTADOR LA LLAMARÁ DENTRO DE VARIOS DÍAS SI LA ENCUESTA NO LLEGA POR CORREO.)
INTRODUZCA MWW SI LA MADRE DICE QUE QUIERE HACER LA ENCUESTA POR INTERNET.
(NOTA: DÍGALE A LA MADRE QUE LE MANDARA UN EMAIL CON EL SITIO DE INTERNET Y SU CODIGO PERSONAL)
PIDE SU EMAIL DE LA MADRE: ____________________.
SI LA MADRE NO TIENE EMAIL, OFRECE MANDARLE UNA CARTA POR CORREO QUE INCLUYE EL SITIO DE INTERNET Y SU CODIGO PERSONAL.
DÍGALE A LA MADRE QUE UN ENTREVISTADOR LA LLAMARÁ DENTRO DE VARIOS DÍAS SI ELLA NO HA LLENADO LA ENCUESTA POR INTERNET.
GO TO PAGE WHERE RESPONDENT LEFT OFF AND CONTINUE THE QUESTIONNAIRE.
Special Text at the Conclusion of the Interview
In certain situations it may be necessary to include special text at the end of the telephone interview. If a reward is sent to responders, the interviewer may need to verify the mother’s address or give the mother a choice of rewards from which to choose. This text is not part of the telephone survey but is incorporated into the CATI software.
If your state includes special text at the conclusion of the telephone interview, provide the exact text here. Any additional information collected from the mother must be recorded manually by the interviewer. The text will appear on the CATI screens but the CATI system will not record any responses.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | LDF8 |
| File Modified | 0000-00-00 |
| File Created | 2024-11-23 |