0920-24BQ Att 3. CAN Focus Group Eligible Participant Screener rev

Attachment 3: CAN Focus Group Eligible Participant Screener

OMB Control No. 0920-1154

Exp. Date 3/31/2026

The public reporting burden of this collection of information is estimated to average 2 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 D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-1154).

[For recruiter to use when recruiting focus group participants]

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 child abuse and neglect and its prevention. The focus group will take about 60 minutes. To thank you for your time, you will receive a $40 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. How old are you?

   1. under 18 years of age (STOP HERE)

   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

3. What is your preferred language?

   1. English

   2. Spanish

   3. American Sign Language

   4. Other [open-ended]

4. What is your Ethnicity?

   1. Hispanic or Latino

   2. Not Hispanic or Latino

   3. Prefer not to answer/Decline

5. 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

6. Are you: Mark all that apply.

   1. Female

   2. Male

   3. Transgender, non-binary, or another gender

   4. Prefer not to answer/Decline

7. What is the highest grade or year of school that you completed?

   1. Never attended school

   2. Attended kindergarten

   3. Grades 1 through 8 (Elementary)

   4. Grades 9 through 11 (Some high school)

   5. Grade 12 or GED (High school graduate)

   6. College 1 year to 3 years (Some college or technical school)

   7. College 4 years or more (College graduate)

   8. Graduate school

   9. I don’t know

8. Last year, (2022), 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+

   9. I don’t know

9. Do you currently have or are the primary caregiver for children under the age of 18?

   1. Yes

   2. No

10. If you are interested in participating in a discussion about messages related to child abuse and neglect, please give us your contact information (recruiter 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 discussion.

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: