Form 0920-25BP Focus Group Screener

Form Approved

OMB Control No.: 0920-1154

Expiration date: 03/31/2026

CDC Division of Vector-Borne Diseases 

Focus Group Screener for Pregnant/Planning to Become Pregnant Travelers

to At-Risk Countries

Updated: October 4, 2024  

 

Introduction

Hello. My name is ________ and I’m calling from _________, an independent communications firm.

You indicated that you are interested in participating in a group discussion, conducted virtually, to discuss healthcare-related topics. [DO NOT DISCLOSE THE EXACT TOPIC OF DISCUSSION BEFORE THE INTERVIEW.] The discussion will last up to 1 hour and 30 minutes. The sole sponsor of this activity is the Centers for Disease Control and Prevention (CDC).

I have a few questions to start. But first, to maintain participants’ confidentiality, we will use first names only during the interview and your name will not be used in any study materials. CDC will not receive any personally identifying information that you provide. We will be asking you a few questions to ensure we are recruiting a variety of people, but the information will not be associated with your specific name.

IF TERMINATED DURING SCREENING PROCESS, READ: I’m sorry, we already have enough individuals in that category. Thank you very much for your time.

INTERVIEWER INSTRUCTION: If individual expresses concern at any point during the screening process, please note their concern and reassure them appropriately. Remind them that their answers and participation will be completely confidential.

Name: _______________________________________________________

Address (residence): _______________________________________________________

City, State, Zip: _______________________________________________________

Phone: _______________________________________________________

Email: _______________________________________________________

Recruiter: _______________________________________________________

SEPARATE CONTACT SHEET FROM THE REST OF THE SCREENER AND SHRED AT THE END OF THE PROJECT.

Recruit Summary

Segment	Audience	FGs / Recruits
A	Caribbean - travel to Cuba or Dominican Republican	2 / 16
B	South America – travel to Brazil, Bolivia, Colombia, or Peru	1 / 8

Primary Screening and Quota Questions

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

Female		CONTINUE
Male		TERMINATE
Unknown	

2. How do you describe your current gender? You can select all that apply.

Female		CONTINUE
Male		TERMINATE
Transgender	
Something else	

3. Do you currently live the majority or all of the year in the United States?

 

Yes		CONTINUE
No		THANK AND TERMINATE

4. What is your age? [RECORD EXACT AGE; DO NOT READ LIST]

17 OR YOUNGER		THANK AND TERMINATE
18 TO 34		CONTINUE
35-44	
45-54	
55 OR OLDER		THANK AND TERMINATE

5. Which of the following best describes your current pregnancy status?

I am currently pregnant		CONTINUE, RECRUIT A MIX OF PREGNANT/CURRENTLY PREGNANT FOR EACH GROUP
I am not currently pregnant but am strongly considering becoming pregnant in the next 12 months	
I am not currently pregnant but am strongly considering becoming pregnant in the next 2-3 years		THANK AND TERMINATE
I do not anticipate becoming pregnant in the next 2-3 years		THANK AND TERMINATE

6. Have you traveled outside of the United States within the last five years? 

 

Yes		CONTINUE
No		THANK AND TERMINATE

 

1. Are you planning to travel outside of the United States within the next 12 months?

Yes		CONTINUE
No		TERMINATE ALL

 

2. Have you visited any of the following countries in the past five years? How many times have you visited in the past 5 years? RECORD NUMBER FOR EACH

 

Cuba		SEGMENT A, RECRUIT 16
Dominican Republic
Brazil		SEGMENT B, RECRUIT 8
Bolivia
Columbia
Peru
None of the above		THANK AND TERMINATE

MUST HAVE VISITED A LOCATION TWICE IN THE PAST 5 YEARS TO CONTINUE FOR THE CORRESPONDING FOCUS GROUP

7. Are you planning to visit any of the following countries within the next 12 months? Only ask future plans for those they have visited in question 8

Cuba		SEGMENT A, RECRUIT 16
Dominican Republic	
Brazil		SEGMENT B, RECRUIT 8
Bolivia	
Columbia	
Peru	

MUST BE PLANNING TO VISIT THE QUALIFYING LOCATION THEY INDICATED IN QUESTION 8, PAST TRAVEL, AT LEAST ONCE IN THE NEXT 12 MONTHS TO CONTINUE

8. When you travel to [QUALIFYING COUNTRY FROM PREVIOUS], Would you say the areas you typically travel to is …

Urban		RECRUIT A MIX
Suburban	
Small town	
Rural	
Not sure		[OK TO CONTINUE IF OTHERWISE QUALIFIES]

Additional Demographic Quota Questions

9. How many times within the past six months have you participated in a focus group or one-on-one interview on a health topic? [DO NOT READ RESPONSE CATEGORY]

None		CONTINUE
1 or more		THANK AND TERMINATE

3. Do you, a spouse or partner, or a child, work in any of the following fields, or have any of you worked in any of the following fields in the past?

 

Market research, communications, public relations, or advertising		THANK AND TERMINATE
Health care or public health
Pharmaceuticals, health sciences, or medical device manufacturing
Federal or state government
None of the above		CONTINUE

10. Are you a parent or guardian of a minor under the age of 18?

Yes	CONTINUE
No

11. In what city and state do you live? [RECORD CITY & STATE, ALSO CODE TO TABLE]

Northeast		CONTINUE
South
Midwest
West

12. Which of the following best describes the area where you live?

Urban		MAX 4 URBAN PER GROUP
Suburban
Small town
Rural

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

Less than high school		RECRUIT A MIX
High school graduate or equivalent
Some college, no degree
Associate degree
Bachelor’s degree
Post-graduate degree

14. Which of the following includes your total annual household income for the last year?

Less than $25,000		RECRUIT A MIX
$25,000 to under $35,000
$35,000 to under $50,000
$50,000 to under $75,000
$75,000 to under $100,000
$100,000 to under $125,000
$125,000 to under $150,000
$150,000 or more

15. Are you able and comfortable participating in a focus group discussion conducted in English?

Yes		CONTINUE
No		THANK AND TERMINATE

NOTE: Participants must speak English very clearly and be able to participate in the discussion with a laptop or desktop computer in front of them so they can clearly see and read the materials that our moderator will show using a shared screen.

Invitation

Thank you for answering all my questions. As I mentioned, we respect your privacy and understand this information is confidential, and we will not disclose this information to anyone. We asked these questions because we want to speak with a variety of people who can provide their opinions and perspectives. Based on your answers to the questions, we would like to invite you to participate in a virtual focus group that will last approximately 90 minutes. During the discussion, you will need to have a reliable internet connection and use a desktop or laptop computer.

You will receive $75 as a token of appreciation for your participation, which will be provided to you after you complete the discussion.

All of your feedback will be confidential, reported in the aggregate only, never in association with your name or identity. To make sure we capture your remarks accurately, we will record the focus group. The purpose of the audio recording is to make sure we report accurately, but without any personally identifying information. Is this something you are interested in and comfortable with?

Yes		CONTINUE
No		THANK AND TERMINATE

The focus group is virtual, meaning that you can participate from the comfort of your home or office. You will not need to come to a facility and can meet us from wherever you are, but you will need to be in front of a computer or tablet with internet access. The information or materials you will review could include reading and visual content, so we request that you do not participate using a cell phone. You will also have to be in a quiet place. Someone will contact you before the focus group to make sure all the technology needed is working properly. Is this focus group something you are interested in and comfortable with?

Yes		CONTINUE
No		THANK AND TERMINATE

CONFIRM DATE AND TIME OF INTERVIEW

Please provide the best telephone number to reach you: RECORD PHONE NUMBER

Please indicate how you would like us to confirm with you: PHONE OR EMAIL, RECORD EMAIL IF PREFERENCE

SEPARATE THE LAST PAGE (CONTACT SHEET) AND SHRED AT THE END OF THE PROJECT

Public reporting burden of this collection of information is estimated to average 5 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 H21-8, Atlanta, Georgia 30333; ATTN: PRA 0920-1154

RECRUITMENT SCREENER: CDC DVBD Focus Groups, 2024 | 1