0920-24CA Attachment 2 - CDC DVBD - AGS Data Collection - Intervie

Form Approved

OMB Control No.: 0920-1154

Expiration date: 03/31/2026

CDC Division of Vector-Borne Diseases

Interview Screener for Providers on Alpha-Gal Syndrome

Updated: December 14, 2023

Hello. My name is ________ and I’m calling from _________, an independent communications firm.

You indicated that you are interested in participating in an interview on topics that may matter or be interesting to you. [DO NOT DISCLOSE THE EXACT TOPIC OF DISCUSSION BEFORE THE INTERVIEW.] The discussion will last approximately 60 minutes. The sole sponsor of this activity is the Centers for Disease Control and Prevention (CDC). To maintain participants’ confidentiality, the interviewer will use first names only during the discussion, and no part of your name be used in any transcripts or reports available to CDC. CDC is not interested in any of your personal information. At this stage, we will be asking you a few questions to ensure we are recruiting a variety of people only.

I have a few questions to start.

[IF TERMINATED DURING SCREENING PROCESS, READ:] I’m sorry, we already have enough individuals in that category. Thank you very much for your time.

INTERVIEWER INSTRUCTION: If an individual expresses concern at any point during the screening process, please note their concern and reassure them appropriately. Remind them that their answers and participation will be completely confidential.

Name: _______________________________________________________

Address (residence): _______________________________________________________

City, State, ZIP: _______________________________________________________

Phone: _______________________________________________________

Email: _______________________________________________________

Recruiter: _______________________________________________________

SEPARATE CONTACT SHEET FROM THE REST OF THE SCREENER AND SHRED AT THE END OF THE PROJECT.

Recruit Summary

Segment	Audience	Number to Recruit
A	Adult primary care physicians	3
B	Emergency care physicians	2
C	Gastroenterology physicians	2
D	Allergist or immunology physicians	2

Screening Questions

1. Are you…?

Female		MAX 5 EITHER GENDER
Male
Transgender, non-binary, or another gender

2. Are you a...?

Medical Doctor (MD)		CONTINUE MAX 1 DO PER PHYSICIAN AUDIENCE
Doctor of Osteopathic Medicine (DO)
Physician Assistant (PA)		TERMINATE ALL
Nurse Practitioner (NP)
Pharmacist (hold a PharmD)
Other (Please specify)

3. What is your medical specialty?

Primary care, internal medicine, or family medicine (specify if so)		CONTINUE
Gastroenterology
Emergency medicine
Allergy or immunology
Something else (please specify)		TERMINATE ALL

4. Do you have a sub-specialty in addition to your specialty? If so, what is it? RECORD

5. What percent of your time is dedicated to your sub-specialty?

Less than 25%
Between 25% and 75%		TERMINATE ALL
75% or more

6. Are you currently in residency or a fellowship program as part of your training in your specialty or subspecialty?

Yes		TERMINATE ALL
No		CONTINUE

7. Is direct patient care your primary responsibility? (Direct contact with patients for the purpose of diagnosis, treatment, and monitoring.)

Yes		CONTINUE
No		TERMINATE ALL

8. On average, how many hours per week do you spend in direct patient care? RECORD ACTUAL HOURS

20+ hours		CONTINUE
Less than 20 hours		TERMINATE ALL

9. Of those hours, what percentage is dedicated to adult care?

50% or more		CONTINUE
Less than 50%		TERMINATE

10. Which of the following best describes your practice setting?

Hospital-based clinic or practice		CONTINUE
Hospital-based emergency department
Urgent care or immediate care clinic
Community health center
Solo practice
Primary care or specialty clinic
Single specialty group practice
Multi-specialty group practice
Other (specify)		KRC TO REVIEW

• PRIMARY CARE:

  • Must have primary care, internal, medicine, or family medicine as specialty.

  • Must not work in emergency department.

• GASTROENTEROLOGY:

  • Must have gastroenterology as specialty.

  • Must not work in emergency department.

• EMERGENCY CARE:

  • Must have emergency medicine as specialty.

  • Must work in emergency department.

• ALLERGIST:

  • Must have allergy or immunology as specialty.

  • Must not work in emergency department.

11. In which state do you practice? RECORD STATE

Northeast		MAX 4 IN ANY ONE REGION TOTAL. NO DUPLICATE REGIONS PER PROVIDER AUDIENCE.
South
Midwest
West		TERMINATE ALL

12. Do you work at or are you affiliated with any of the following?

A public health department		TERMINATE ALL
Federal or state government
Pharmaceutical company or research lab
None of the above		CONTINUE

13. The following is a list of medical conditions. For each one, please tell me whether you are very familiar, somewhat familiar, not familiar but aware, or not at all aware. READ IN RANDOM ORDER, RECORD FOR EACH

Alpha-gal syndrome, or any of alpha-gal allergy, red meat allergy, or tick bite meat allergy		MUST BE “VERY,” “SOMEWHAT,” OR “NOT FAMILIAR BUT AWARE” TO QUALITY
Coccidioidomycosis, also called valley fever		CONTINUE (DUMMY TOPICS TO MASK SUBJECT)
Chikungunya virus
Mpox, also called monkeypox
Shigellosis

14. In what year did you receive your highest medical degree?

1973 or before		MAX 2
1974-1983
1984-1993		CONTINUE
1994-2003
2004-2013
2014-2019
2019 or after		MAX 2

15. How would you describe the location where you work?

Urban		MAX 5 URBAN + SUBURBAN
Suburban
Small town		MAX 5 SMALL TOWN + RURAL
Rural

16. Are you of Hispanic, Latino, or Spanish origin?

Yes		CONTINUE
No

17. What is your race? Choose all that apply.

American Indian or Alaska Native		CONTINUE
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Another race

RECRUIT MINIMUM 2 WHO ARE HISPANIC, LATINO, SPANISH, OR NON-WHITE

18. Which of the following is the most common insurance status for your patients?

Covered by private insurance		CONTINUE
Covered by public insurance		MAX 3
Uninsured		MAX 2

19. How many times within the past three months have you participated in a focus group or one-on-one interview related to your professional expertise? DO NOT READ LIST

None		CONTINUE
1 or more		TERMINATE ALL

Invitation

Thank you for answering all of my questions. As I mentioned, we respect your privacy and understand this information is confidential, and we will not disclose this information to anyone outside of the project team. We asked these questions because we want to speak with a wide variety of people who can review important information and provide their feedback. Based on your answers to the questions, we would like to invite you to participate in a 60-minute interview.

You will receive $75 as a token of appreciation for your participation, which will be provided to you after you complete the interview.

All of your feedback will be confidential, never in association with your name. To make sure we capture your remarks accurately, we will audio and video record the interview. The purpose of the recording is to make sure we report accurately, we will not include your name in the transcript. After approval of the final report, recordings will be deleted. Is this interview something you are interested in and comfortable with?

Yes		SHARE DATE AND TIME OF INTERVIEW
No		TERMINATE ALL

Additionally, the interview is virtual, meaning that you can participate from the comfort of your home or office. You will not need to come to a facility and can meet us from wherever you are, but you will need to be in front of a computer or tablet with internet access and camera so you can be on screen. You will also have to be in a quiet place. Someone will call you before the interview to make sure all the technology needed for the discussion is working properly. Is this something you are interested in and comfortable with, and do you have access to a computer or tablet to fulfill these requirements?

Yes		CONTINUE
No		TERMINATE ALL

FOR SCHEDULED PARTICIPANTS:

The interview will occur on DATE, at TIME. Before your scheduled discussion, we will send you confirmation with all the required logistical and technological information. If you wear reading glasses or use a hearing aid, please remember to have those with you for the interview.

If you must cancel, please let us know immediately, so we can find someone to take your place. My name is ___________ and you can reach me at _____________.

SEPARATE FIRST PAGE (CONTACT SHEET) AND SHRED AT THE END OF THE PROJECT

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 Reports Clearance Officer, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA 0920-1154