Form 0920-1154-24CC Recruitment Materials - Focus Groups and Interviews - AI

Division of Injury Prevention

HEADS UP! Outreach to At-Risk Groups (13553)

OMB Control No. 0920-1154

Exp. Date: 03/31/2026

The public reporting burden of this collection of information is estimated to average 8 minutes per response, including the time for reviewing instructions, 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 D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-1154).

Recruitment Materials - Focus Groups and Interviews

AI/AN Adults

Date	January 9, 2023

Project Summary

The goal of this focus group discussion is to learn from you about what you know about concussions and what you think about the current concussion and mild Traumatic Brain Injury (TBI) medical discharge instructions. This information will help us develop appropriate concussion discharge instructions for adult Alaska Natives and American Indians, Native people, and Tribal members. This project is being conducted for the Centers for Disease Control and Prevention, also known as the CDC.

Recruitment Eligibility Screener

1. What is your ethnicity?

   1. Hispanic or Latino

   2. Not Hispanic or Latino

   3. Prefer Not to Answer/Decline

2. What is your race (select all that apply)

   1. American Indian or Alaska Native

   2. Asian

   3. Black or African American

   4. Native Hawaiian or Other Pacific Islander

   5. White

   6. Prefer Not to Answer/Decline

3. Do you identify as American Indian or Alaska Native?

   1. Yes

   2. No (Terminate)

4. Are you 18 years of age or older?

   1. Yes

   2. No (Terminate)

5. Gender Identity: how do you currently describe yourself (please select all that apply)?

1. Female

2. Male

3. Transgender

4. I use a different term [free-text entry]

5. Prefer not to answer/decline

6. What is your zip code? [open-ended]

7. What Tribe are you affiliated with? [open-ended]

8. How old are you?

   1. under 18 years of age

   2. 18-24 years of age

   3. 25-34 years of age

   4. 35-44 years of age

   5. 45-54 years of age

   6. 55-64 years of age

   7. 65-74 years of age

   8. 75 years of age or older

9. Have you experienced a head injury, concussion, or traumatic brain injury?

   1. Yes

   2. No

   3. I Don’t Know

10. Do you know anyone who has experienced a head injury, concussion, or traumatic brain injury?

    1. Yes

    2. No

    3. I Don’t Know

11. (FOR TRIBAL HEALTHCARE PROVIDERS) Do you provide medical, clinical, or healthcare-related services for Tribal members and communities?

    1. Yes

    2. No (Terminate)

12. (FOR TRIBAL HEALTHCARE PROVIDERS) Have you treated a patient for a head injury, concussion, or traumatic brain injury in the last 12 months?

    1. Yes

    2. No

    3. I Don’t Know

13. (FOR TRIBAL HEALTHCARE PROVIDERS) Have you ever treated a patient for a head injury, concussion, or traumatic brain injury?

    1. Yes

    2. No

14. (FOR TRIBAL LEADERS) Do you identify as a Tribal Leader? (This could be a Tribal Elder, councilman or councilwoman, chief/chieftain/chieftess, or other position of leadership or person of significant influence within your Tribal community)

    1. Yes

    2. No (Terminate)

15. We are holding a virtual group discussion online where you would use your phone, tablet, or computer to join. Are you comfortable participating in a virtual discussion?

    1. Yes

    2. No (Terminate)

16. Do you have a device that has a camera that faces you that would allow you to participate in a virtual discussion?

    1. Yes

    2. No (Terminate)

17. What kind of device or devices do you have with a camera that faces you that would allow you to participate in a virtual discussion?

    1. Tablet

    2. Desktop computer

    3. Laptop computer

    4. Phone

18. Do you have access to Zoom on this device?

    1. Yes (Skip to Question 11)

    2. No (Proceed to Question 10.2)

    3. I Don’t Know (Proceed to Question 10.2)

12.2 [If answered “no” or “I Don’t Know” on Question 10] Can you download and install new programs on your device, or do you need someone to help you?

1. Yes, can install

2. Can install with help

3. Don’t know

4. No, cannot install/need administrator

If excluded, Termination Language: Thank you for your interest. Unfortunately, you do not meet the qualifications to participate in this study.

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