0920-1154 Eligible Participant Screener (24CU)

Form Approved

OMB No. 0920-1154

Exp. Date: 3/31/26

Attachment 3 - Eligible Participant Screener

Eligible Participant Screener for Interview/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 interview . We will ask a series of questions about food and water safety. The interview will take about 60 minutes. We will require your full attention, so we ask that you are not working or on call during the interview. To thank you for your time, you will receive a [$350 for Medical Doctors and $250 for other healthcare providers] token of appreciation for your participation.

Do you have any questions?

Are you interested in participating in the interview ?

□ Yes (CONTINUE)

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

CONFIRM NAME, HEALTHCARE PRACTICE INFORMATION, 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. Where do you provide healthcare services? [County and State]

   1. Need representation from both rural and urban areas

3. Where do you primarily see patients? (select all that apply)

   1. Private practice (individual or group)

   2. Public or University Based practice

   3. Other [please specify]

4. Can you describe the patient population that you typically care for/work with?

5. On average, how many patients do you see in a month?

6. How many years have you been in practice?

7. What is your age?

8. How do you currently describe yourself (mark all that apply)?

   1. Female

   2. Male

   3. Transgender

   4. I use a different term [please specify]

   5. Prefer not to answer/Decline

9. Which of the following best describes your ethnicity?

1. Hispanic or Latino

2. Not Hispanic or Latino

3. Prefer not to answer/Decline

10. 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

11. If you are interested in participating in a discussion about food and water safety, 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 interview . As a reminder, we require your full attention during the interview and ask that you select a time when you are not working or on call.

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:

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).