Form 0920-1154 Screening/Eligibility Form for Focus Groups

Form Approved

OMB Control No.: 0920-1154 Expiration date: 3/31/2026

Screening/Eligibility Form for Focus Groups

(form to be read and conducted by recruiter)

1. Are you comfortable speaking and reading in English?

   1. Yes [ELIGIBLE; CONTINUE]

   2. No [INELIGIBLE; STOP]

   3. Don’t Know [INELIGIBLE; STOP]

2. What is your age? [Record age.]

   1. Age 18+ [ELIGIBLE; CONTINUE]

   2. Age <18 years [INELIGIBLE; STOP]

   3. Refused [INELIGIBLE; STOP]

3. Have you participated in any focus group, interview, telephone survey, or online survey in which you were asked your opinions about a product, a service, or advertising within the past six months?

   1. No [ELIGIBLE; CONTINUE]

   2. Yes [INELIGIBLE; STOP]

4. Have you participated in any research studies about wastewater monitoring in the past 4 years?

   1. No [ELIGIBLE; CONTINUE]

   2. Yes [INELIGIBLE; STOP]

5. Have you worked in any of the following areas within the past 2 years?

• market research

• graphic design or website design

• advertising or public relations

• media (TV/radio/newspapers/magazines/social media)

• healthcare (e.g., doctor, nurse, pharmacist, dietician, etc.)

• federal government

• infectious disease research, sample testing, or surveillance

1. No [ELIGIBLE; CONTINUE]

2. Yes [INELIGIBLE; STOP]

The discussion we would like you to participate in will take place on the computer.  The next few questions will involve technology – please answer these questions considering the computer you will be using to join the focus group. 

6. Do you currently have access to high-speed (define minimum speed) internet – again considering the location and computer you will be joining the discussion from?

[    ] Yes

[    ] No TERMINATE

7. What type of computer will you be using?

[ ] Laptop

[ ] Desktop

[ ] Tablet

[ ] I do not have access to a laptop or desktop -TERMINATE

8. Do you currently have a working webcam on your computer (whether built in or plug in)?

[ ] Yes – Built In

[ ] Yes – External

[  ] No- TERMINATE

9. Do you have access to an active email account?

[    ] Yes – RECORD CAREFULLY ________________________________________

[    ] No TERMINATE

This account is where we will send your confirmation email with important instructions on how to join the session.

ELIGIBILITY CHECK:

□ Yes □ No

Date: Initials:

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 H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-1154).

Highly Sensitive/Any User (No encryption)

Highly Sensitive/Any User (No encryption)

Highly Sensitive/Any User (No encryption)

Highly Sensitive/Any User (No encryption)