0920-1154 Eligibility Screener - Survey

Eligibility Screener for Survey

CDC estimates the average public reporting burden for this collection of information as 2 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 D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1154).

We are going to see if you are eligible for this survey.

1. What is your age range?

   1. Below 18 [INELIGIBLE]

   2. 18-35

   3. 36-65

   4. 65+

2. IF FOODBORNE OUTBREAK/MESSAGE TESTING: Do you shop for and/or prepare [INSERT NAME OF FOOD/PRODUCT] for your household?

   1. Yes

   2. No

3. Have you or anyone in your house experienced a [foodborne, waterborne, or fungal] illness in the past year?

   1. Yes

   2. No
      
      

4. Do you own a pet?

   1. Yes

   2. No

5. Have you participated in any outdoor events/activities recently for recreation or work (e.g., hiked/walked on a trail, swam in a lake/river/reservoir/pond/ocean, visited a park, gardened, played an outdoor sport (e.g., soccer, running)?

   1. Yes

   2. No
      
      

6. Does your occupation fall into one of these categories? If so, please select which one best describes your field of work.

   1. Agriculture

   2. Archeology

   3. Construction, excavation, and/or demolition

   4. Forestry work

   5. Geology

   6. Landscaping or tree removal

   7. Military

   8. Mining, quarrying, gas, and oil extraction

   9. Occupations or industries exposed to bird or bat droppings

   10. Occupations or industries that disrupt the environment (soil or plant matter disruption)

   11. None of the above [EXCLUSIVE]
       
       

7. Do you or anyone in your household have a medical condition that weakens your immune system? Examples of diseases or conditions that can weaken your immune system include HIV, diabetes, cancer, lupus, inflammatory bowel disease, kidney disease, liver disease, multiple sclerosis, and receiving an organ transplant.

   1. Yes

   2. No
      
      

8. Are you pregnant or have you been pregnant within the last year?

   1. Yes

   2. No

   3. Prefer not to answer

9. Are you the caregiver for a child under the age of 5 or an adult 65+?

   1. Yes

   2. No

   3. Prefer not to answer

[IF INELIGIBLE, SHARE THE FOLLOWING STATEMENT:] [Thanks, we’re focusing this study on particular issues and on this occasion you do not meet the research qualifications. We sincerely thank you and appreciate your time, dedication, and continued participation in our online studies.]

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