0920-1154 Eligible Participant Screener for Focus Group (24CP)

Form Approved

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

Eligible Participant Screener for Focus Group (to be conducted over the phone by recruiter)

Good news. You are eligible to participate in this project.

If you agree to participate in this project, we will ask you to take part in a web-based focus group. We will ask a series of questions about wastewater monitoring. This focus group will take about 60 minutes. To thank you for your time, you will receive a $75 token of appreciation for your participation.

Do you have any questions?

Are you interested in participating in the focus group?

□ Yes (CONTINUE)

□ No, Okay, thank you for your time today. (STOP HERE)

CONFIRM NAME, DEMOGRAPHICS, EMAIL, AND PHONE

1. Could you please spell your first and last name?

I have a few additional questions to ensure we get a good mix of participants in this study.

2. In what ZIP code do you currently live? [ENTER FIVE DIGIT ZIP CODE]

3. How would you describe the area where you live?

1. Rural

2. Urban

3. Suburban

4. Are you the parent or caregiver of a child(ren) who currently lives in your household?

   1. Yes

   2. No

   3. Prefer not to answer

5. Are you the caregiver of any elderly individuals who currently live in your household?

   1. Yes

   2. No

   3. Prefer not to answer

6. Are you the owner or co-owner of a business in your community?

   1. Yes

   2. No [IF NO, SKIP TO QUESTION 10]

7. Do you make decisions about staffing or business opening/closing?

   1. Yes

   2. No [IF NO, SKIP TO QUESTION 10]

8. Does your business have a physical storefront?

   1. Yes

   2. No [IF NO, SKIP TO QUESTION 10]

9. Does your business staff six or more employees who work together in-person on a weekly basis?

   1. Yes

   2. No [IF NO, SKIP TO QUESTION 10]

10. What sex were you assigned at birth, on your original birth certificate?

    1. Female

    2. Male

11. How do you currently describe yourself? [mark all that apply]

    1. Female

    2. Male

    3. Transgender

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

    5. Prefer not to answer/Decline

12. Just to confirm, you were assigned {FILL} at birth and now you describe yourself as {FILL}. Is that correct?

    1. Yes

    2. No [skip back to Q1 and/or Q2 to correct]

13. Which of the following best describes your ethnicity?

1. Hispanic or Latino

2. Not Hispanic or Latino

3. Prefer not to answer/Decline

14. Which of the following best describes your race? [Please select one or more as applicable].

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

15. What is the highest level of education you have completed?

1. Some high school

2. High school diploma

3. Some college or associate's degree

4. Bachelor’s degree

5. Advanced degree

6. Prefer not to answer/Decline

16. What is your current occupational status? Would you say…?

    1. Employed full time

    2. Employed part time

    3. Unemployed

    4. Stay at home parent

    5. Student

    6. Retired

    7. Disabled

    8. Other:_______________

    9. Don’t Know/Not Sure [DO NOT READ]

    10. Prefer not to answer

17. Last year, in 2023, what was your total household income from all sources, before taxes?

    1. Less than $15,000

    2. $15,000 to $24,999

    3. $25,000 to $34,999

    4. $35,000 to $49,999

    5. $50,000 to $74,999

    6. $75,000 to $99,999

    7. $100,000 to $149,999

    8. $150,000+

18. Do you have any of the following conditions?

    1. HIV

    2. Cancer

    3. Diabetes

    4. Liver disease

    5. Kidney disease

    6. Lupus

    7. Multiple sclerosis (MS)

    8. Inflammatory bowel disease (IBD)

    9. Organ transplant recipient

    10. Any other immunocompromised conditions? [Ask to Specify]

    11. Prefers not to answer

19. If you are interested in participating in a discussion about wastewater monitoring, please give us your contact information (interviewer will fill out contact information card) below. If you are chosen for the project, a team member will contact you to arrange a convenient time for the focus group.

PARTICIPANT PREFERRED CONTACT INFORMATION
PARTICIPANT NAME:
Cell:	Home (other phone):
EMAIL (must be an email address that is used frequently):
Best time and way to reach:

Segmentation Table (for recruiter use)

Population	Segmentation	Number of Focus groups	Number of Participants
Caregivers (of children and elderly individuals)	Caregivers of children under 5	1	8-10
	Caregivers of elderly individuals	1	8-10
Business Leaders	General population (not including low education individuals)	1	8-10
	Low education (less than high school diploma)	1	8-10
Individuals at high risk of viral diseases	N/A	1	8-10
Rural Populations	N/A	1	8-10
Total		6	48-60

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).