Form 0920-1154 Screening/Eligibility Form for Interviews/Focus Groups (

Form Approved

OMB No. 0920-1154

Exp. Date: 3/31/26

Screening/Eligibility Form for Interviews/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. Are you a healthcare provider?

   1. Yes [ELIGIBLE; CONTINUE]

   2. NO [INELIGIBLE; STOP]

3. Do you work in a clinical setting where you regularly interact with patients?

   1. Yes [ELIGIBLE; CONTINUE]

   2. NO [INELIGIBLE; STOP]

4. What type of healthcare provider describes you?

1. Primary Care Physician (PCP) or Family/Internal Medicine Physician [ELIGIBLE; CONTINUE TO 5A]

2. Obstetrician/Gynecologist (OBGYN) [ELIGIBLE; CONTINUE TO 5A]

3. Pediatrician [ELIGIBLE; CONTINUE TO 5A]

4. Oncologist [ELIGIBLE; CONTINUE TO 5A]

5. Nurse Practitioner (NP) [ELIGIBLE; CONTINUE TO 5A]

6. Physician Assistant (PA) [ELIGIBLE; CONTINUE TO 5A]

7. Other (specify) [ELIGIBLE; CONTINUE TO 5B]

5. 5A Do you work at a federally qualified health center (FQHC) or community health center?

   1. Yes [ELIGIBLE; CONTINUE]

   2. No [ELIGIBLE; CONTINUE]

5B [FOR “OTHER” TYPES OF HCPs] Do you work at a federally qualified health center (FQHC) or community health center?

3. Yes [ELIGIBLE; CONTINUE]

4. No [INELIGIBLE; STOP]

   • [NOTE: that this means the individual is not one of the given types of healthcare providers in question 4, and they do not work for an FQHC/community health center.]

6. Does part of your role involve discussing health-related behaviors (e.g., diet, physical activity) with your patients?

   1. Yes, this is part of my role [ELIGIBLE; CONTINUE]

   2. No, this is not part of my role [INELIGIBLE; STOP]

7. [ONLY FOR NURSE PRACTITIONERS OR PHYSICIAN ASSISTANTS] Which area of medicine do you work in? [select all that apply]

   1. Anesthesia

   2. Cardiology

   3. Dermatology

   4. Emergency medicine

   5. ENT/Otolaryngology

   6. Family medicine

   7. General practice

   8. Internal medicine

   9. Neurology

   10. Obstetrics and gynecology (OB/GYN)

   11. Radiology

   12. Pediatrics

   13. Surgery

   14. Other (specify)

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

8. Do you have access to a computer or tablet?

   1. Yes [ELIGIBLE; CONTINUE]

   2. No [INELIGIBLE; STOP]

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

[    ] Yes

[    ] No - TERMINATE

10. What type of computer/tablet will you be using?

[ ] Laptop

[ ] Desktop

[ ] Tablet

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

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

[ ] Yes – Built in or external

[  ] No - TERMINATE

12. 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.

13. What internet browser do you use (e.g., Internet Explorer, Chrome, Safari, Firefox, Edge)?   ________________________________________

Internet Explorer is NOT supported at all. Only continue with the respondent if they are willing to download a compatible browser. Chrome, Firefox, Edge, and Safari are compatible. All others, hold and check with the client.

If Internet Explorer is their answer: Would you be willing to download another browser to use for the test/live session?

[ ] YES- CONTINUE

[ ] NO- TERMINATE

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)