Eligibility Screener for Rapid Survey

GenIC Clearance for CDC/ATSDR

Formative Research and Tool Development

Food Safety Communication Evaluation: Assessing Food Safety Messages, Knowledge, and Attitudes

Attachment 9 – Eligibility Screener for Survey

Contact: Sara Bresee

Office of the Director

Division of Foodborne, Waterborne, and Environmental Diseases

Centers for Disease Control and Prevention

1600 Clifton Road, NE

Atlanta, Georgia 30333

Phone: (404) 639.3371

Email: [email protected]

Form Approved

OMB No. 0920-1154

Exp. Date: 3/31/26

Eligibility Screener for Survey

CDC estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1154).

We are going to see if you are eligible for this survey.

1. What is your age range?

   1. Below 18 [UNELLIGIBLE]

   2. 18-35

   3. 36-55

   4. 55+

If UNELLIGIBLE [Thanks, we’re focusing this study on particular issues and on this occasion you do not meet the research qualifications. We sincerely thank you and appreciate your time, dedication, and contiued participation in our online studies.]

2. Do you shop for and/or prepare food for your household? [25% of participants]

   1. Yes

   2. No [ONCE % HAS BEEN REACHED GIVE IF UNELLIGIBLE STATEMENT]

3. Have you or anyone in your house experienced a foodborne illness in the past year? [25% of participants]

   1. Yes

   2. No [ONCE % HAS BEEN REACHED GIVE IF UNELLIGIBLE STATEMENT]

4. Do you or anyone in your household have a medical condition that puts you at higher risk for food poisoning? (e.g., weakend immune system, food allergies) [15% of participants]

   1. Yes

   2. No [ONCE % HAS BEEN REACHED GIVE IF UNELLIGIBLE STATEMENT]

5. Are you pregnant or have you been pregnant within the last year? [15% of participants]

   1. Yes

b. No [ONCE % HAS BEEN REACHED GIVE IF UNELLIGIBLE STATEMENT]

2. Prefer not to answer [ONCE % HAS BEEN REACHED GIVE IF UNELLIGIBLE STATEMENT]

6. Are you the caregiver for a chlid under the age of 5 or an adult 65+ )who is at risk for foodborne illness? [20% of participants]

   1. Yes

   2. No [ONCE % HAS BEEN REACHED GIVE IF UNELLIGIBLE STATEMENT]

   3. Prefer to not answer [ONCE % HAS BEEN REACHED GIVE IF UNELLIGIBLE STATEMENT]

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