Form 0920-0222 NISVS Screener

Attachment 4 – Telephone Screening Script

Form Approved

OMB No. 0920-0222

Exp. Date: 01/31/2026

Notice - 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 Information Collection Review Office, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-0222).

Assurance of Confidentiality: We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act (44 U.S.C. 3561-3583). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note) which protects Federal information systems from cybersecurity risks by screening their networks.

Sample screening script for respondents recruited through the advertisement/flyer

Dial respondent’s telephone number [hereafter referred to as R] as indicated on CCQDER voice mail system or email.

 Note: Speak only to R. If the number is answered by voice mail, say, “This is [CCQDER staff name] from National Center of Health Statistics returning your call. I will call back at another time.”

CCQDER Recruiter/CCQDER Staff: Good morning/afternoon, may I speak to (name)?

 If R is not available or not at home, say, “Thank you” and try again at another time.

If the person who answered the phone (NOT R) asks, “Who is calling?” or “What’s this about?” say, “I am returning their call to me. I’ll try to reach them at another time.”

 If R has been successfully contacted, continue...

“Hello, my name is [CCQDER Recruiter/CCQDER Staff’s name]. I am calling from the National Center for Health Statistics. You may remember that you responded to the advertisement we placed [in [name of newspaper/website] on [date]] or flyer looking for adults who have experienced either sexual violence or intimate partner violence to answer health-related survey questions. Is this a safe time to talk? If you are driving, I will call you back. I can also call you back if you are too busy.”

 Wait for acknowledgment, such as, “This is a safe time to talk.”

“In order to determine if you are eligible for our study, I’ll need a few minutes of your time to ask some background questions. Answering these questions is completely voluntary and takes about 5 minutes. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent. Is this a good time to ask the questions or should I call back later?”

 If not a good time to talk, schedule a time to call back.

 If good time to talk, continue...

1. Where did you see our advertisement/flyer? __________________________________

2. How old are you? ________________ [If under age 18, go to exit script 1]

3. What is your gender? You may select more than one answer.

• Male

• Female

• Transgender, non-binary, or another gender _____________

• Prefer not to say

4. What is the highest level of school you have completed?

• Less than High School (No Diploma or GED)

• High School Diploma or GED

• Associate Degree

• Some College

• Bachelor’s Degree

• Graduate Degree

5. Are you Spanish, Hispanic, or Latino?

• Yes

• No

6. What race or races do you consider yourself to be? You may select more than one race.

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

7. Have you ever experienced any sexual violence?

• Yes

• No

8. Have you ever experienced any intimate partner violence? [If yes, ask 8a & 8b.]

• Yes

• No

8a. Have you ever been choked or strangled by an intimate partner?

• Yes

• No

8b. Has any intimate partner violence ever resulted in an injury to your head or face?

• Yes

• No

[If the recruitment needs for certain demographic groups have been achieved, go to exit script 3]. Otherwise continue.

FOR INTERVIEWS CONDUCTED ONSITE AT NCHS-- Are you a U.S. citizen? [If no, go to exit script 4]

• Yes

• No

FOR INTERVIEW CONDUCTED VIRTUALLY— Are you able to access a computer, tablet or cellphone with internet and video capability? [If no, go to exit script 5]

• Yes

• No

Entry Script for interviews conducted virtually:

...Based on your answers to the questions so far, we would like you to take part in our study. For this study we’d like you to use a computer, tablet, or cellphone to have a video call via Zoom with an interviewer that works at the National Center for Health Statistics. Someone from NCHS will walk you through the process of downloading and setting up Zoom on your device. During the interview, the interviewer will ask you a variety of questions about sexual violence and intimate partner violence. Then the interviewer will ask you to explain what you were thinking as you answered the questions. The interviewer will also ask you about your opinions of the questions. Your answers will help us find out if the survey questions will be easy for other people to answer. NCHS secures all information we collect, process and store on our systems as required by Federal regulations, Executive Orders, and NCHS confidentiality statutes.  However, NCHS cannot secure and protect your personal computing devices, such as personal computer or smart phones, used to complete the NCHS interview.

With your permission, we would like to record your interview. The recording is a record of what we asked and what you said about the questions. Do you give permission to have your interview video recorded? [Yes/No.] [If no, go to exit script 6. At a minimum video recording is essential for this project].

After we talk today, you will be sent a confirmation email with the date and time of your interview. Can we have your email address to send the confirmation email? [Get e-mail.] Attached with the confirmation email will be a consent form. In order to take part in the study you must read the entire consent form. The consent form tells you about the study and what you will be asked to do. If you have any questions about confidentiality, identity protection, procedures or other topics related to the study please contact me [name] at [phone number/email] any time before your interview.  

Do you have any questions at this point?  [Pause to answer questions.]  If (not/you have no other questions), then let’s get you on the schedule, ok?  We will be interviewing (Day, Month/Date) through (Day, Month/Date) from (time to time).  Looking at your schedule, when would you be available to participate?  [Schedule].  [If date/times not available go to exit script 7.]  

 

[If remuneration is cash] What is your mailing address?  We will use this address to send you $50 cash via FedEx after the completion of the interview.  Packages typically take 5 business days to arrive.  

[If remuneration is an electronic gift cards] After your interview, we will email you the activation code for your $50 electronic gift card with a thank you letter. The email will be sent right after your interview, and you will be able to use your electronic gift card immediately after activation.

 

Do you have 5 minutes right now to set up Zoom on the device you will be using for the interview? If not, we can schedule another time to do it prior to the interview. 

 

We ask that you be in a quiet, private space, alone with minimal distractions during your interview. To protect your identity, we ask that no photos or personable identifiable items be visible during the interview. To minimize movement and distractions during the interview please place your device on a stable surface. 

 

A reminder call will be made to you a few days in advance.  Should you have any questions or need to change your appointment, please feel free to contact me [name] at [phone number]. Thank you for responding to our ad, and I look forward to seeing you through Zoom on (DATE/TIME) [Get respondent to cite date & time if possible.]

Entry Script for interviews conducted at NCHS or off-site:

...Based on your answers to the questions so far, we would like you to take part in our study. For this study we’d like you to come here to the National Center for Health Statistics in Hyattsville, Maryland/agreed mutual location. An interviewer will ask you to fill out a questionnaire about sexual violence and intimate partner violence. Then the interviewer will ask you to explain what you were thinking as you answered the questions. The interviewer will also ask you about your opinions of the questions. Your answers will help us find out if the survey questions will be easy for other people to answer. Everything you say will be kept private. With your permission, we would like to record your interview. The recording is a record of what we asked and what you said about the questions. Do you give permission to have your interview video recorded? [Yes/No.] [If no, ask if for permission to audio record]. Do you give permission to have your interview audio recorded? [Yes/No.] [If no, go to exit script 6. At a minimum audio recording is essential for this project].

Do you have any questions at this point? [Pause to answer questions.] If (not/you have no other questions), then let’s get you on the schedule, ok? We will be interviewing (Day, Month/Date) through (Day, Month/Date) from 8 a.m. to 6 p.m. Looking at your schedule, when would you be available to participate? [Schedule.] [If date/times not available go to exit script 7.]

A reminder call will be made to you a few days in advance. Should you have any questions or need to change your appointment, please feel free to contact me [name] at [phone number]. Thank you for responding to our ad, and I look forward to seeing you here at (DATE/TIME) [Get respondent to cite date & time if possible.]

---------------------------------------------------------

Exit script 1: I’m sorry, you have to be 18 years of age or older take part in this study and therefore we won’t be able to use you at this time. We appreciate your call and thank you for your interest in our study.

Exit script 2: I’m sorry, you have not met one of the eligibility requirements for this particular study. However, I would like to put your name and the information you gave me into our database so that I can contact you about other studies coming up in the future. Your information will be kept for up to 5 years and you can decide at any time to be removed from our database. Email [email protected] to request removal. Is that ok? [If yes, record name & number. If no:] OK, thank you for your time.

Exit Script 3: Based upon your answers, it seems that we may already have a number of volunteers with very similar answers to yours. At this point we need to talk with people with some different characteristics. However, if we have cancellations or other slots open up, I may wish to call you back. Would it be okay if I kept your name, telephone number, and the information you provided in response to the eligibility questions until the end of this study? [If yes,] make notation. [If no,] would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? Your information will be kept for up to 5 years and you can decide at any time to be removed from our database. Email [email protected] to request removal. [ If yes, add to database. If no:] OK, thank you for your time. Your name and any information you gave me will not be added to our database.

Exit script 4: I’m sorry, all Federal Government facilities require screening procedures for non-U.S. citizens. This process can take more than 30 days. Unfortunately, our study has to be completed before your screening process would be complete. Would you be agreeable to having your interview conducted at an offsite location? [If yes,] discuss off-site interviewing locations. [If no,] would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? Your information will be kept for up to 5 years and you can decide at any time to be removed from our database. Email [email protected] to request removal. [If yes, add to database. If no:] OK, thank you for your time. Your name and any information you gave me will not be added to our database.

Exit script 5: I’m sorry, these interviews will be conducted over video chat, and you need a computer, tablet or cellphone with internet to participate; therefore, we won’t be able to schedule you at this time. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? Your information will be kept for up to 5 years and you can decide at any time to be removed from our database. Email [email protected] to request removal. [If yes, add to database. If no:] OK, thank you for your time. Your name and any information you gave me will not be added to our database.

Exit script 6: I’m sorry, willingness to be [FOR VIRTUAL: video/ FOR INTERVIEWS TO BE CONDUCTED AT NCHS: audio] recorded is required in order to take part in this study and therefore we won’t be able to schedule you at this time. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? Your information will be kept for up to 5 years and you can decide at any time to be removed from our database. Email [email protected] to request removal. [If yes, add to database. If no:] OK, thank you for your time. Your name and any information you gave me will not be added to our database.

Exit script 7: I see...ok, we were hoping to complete this particular study between (Month/Date) and (Month/Date), so it looks like we won’t be able to schedule you at this time. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? Your information will be kept for up to 5 years and you can decide at any time to be removed from our database. Email [email protected] to request removal. [If yes, add to database. If no:] OK, thank you for your time. Your name and any information you gave me will not be added to our database.

Sample screening script for respondents recruited through CCQDER Respondent Database

Dial respondent’s telephone number [

hereafter referred to as R] as indicated in the CCQDER Respondent Database.

Note: Speak only to R. If the number is answered by voice mail, say, “This is [CCQDER staff name] from National Center of Health Statistics returning your call. I will call back at another time.”

• CCQDER Recruiter/CCQDER Staff: “Good morning/afternoon, may I speak to (name)?”

• If R is not available or not at home, say, “Thank you” and try again at another time.

• If the person who answered the phone (NOT R) asks, “Who is calling?” or “What’s this about?” say, “I am returning their call to me. I’ll try to reach them at another time.”

• If R has been successfully contacted, continue...

“Hello, my name is [CCQDER Recruiter/CCQDER Staff name]. I am calling from the National Center for Health Statistics. You may remember that you participated in a research study back in [date] testing questions on sexual violence or intimate partner violence. Is this a safe time to talk? If you are driving, I will call you back. I can also call you back if you are too busy.”

• Wait for acknowledgment, such as, “This is a safe time to talk.”

“We are in the process of testing a variety of questions about sexual violence and intimate partner violence and wondered if you might be interested in participating.”

• If R indicates they are interested in participating continue…

• If R indicates they are NOT interested in participating, go to exit script 1.

• “In order to determine if you are eligible for our study, I’ll need a few minutes of your time to ask some background questions. Answering these questions is completely voluntary and takes about 5 minutes. We are required by law to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you without your consent. Is this a good time to ask the questions or should I call back later?”

• If not a good time to talk, schedule a time to call back.

• If good time to talk, continue...

1. How old are you now? _______ [if under age 18, go to exit script 2]

2. What is the highest level of school you have completed?

 Less than High School (No Diploma or GED)

 High School Diploma or GED

 Associate Degree

 Some College

 Bachelor’s Degree

 Graduate Degree

3. What is your gender? You may select more than one answer.

• Male

• Female

• Transgender, non-binary, or another gender _____________

• Prefer not to say

4. Are you Spanish, Hispanic, or Latino?

 Yes

 No

5. What race or races do you consider yourself to be? You may select more than one race.

 American Indian or Alaska Native

 Asian

 Black or African American

 Native Hawaiian or Other Pacific Islander

 White

6. Have you ever experienced any sexual violence?

• Yes

• No

7. Have you ever experienced any intimate partner violence? [If yes, ask 7a & 7b.]

• Yes

• No

7a. Have you ever been choked or strangled by an intimate partner?

• Yes

• No

7b. Has any intimate partner violence ever resulted in an injury to your head or face?

• Yes

• fNo

[If the recruitment needs for certain demographic groups have been achieved, go to exit script 3]. Otherwise continue.

FOR INTERVIEWS CONDUCTED ONSITE AT NCHS-- Are you a U.S. citizen? [If No, go to exit script 5]

• Yes

• No

FOR INTERVIEW CONDUCTED VIRTUALLY— Are you able to access a computer, tablet or cellphone with internet and video capability? [If No, go to exit script 6]

• Yes

• No

Entry Script for interviews conducted virtually:

...Based on your answers to the questions so far, we would like you to take part in our study. For this study we’d like you to use a computer, tablet, or cellphone to have a video call via Zoom with an interviewer that works at the National Center for Health Statistics. Someone from NCHS will walk you through the process of downloading and setting up Zoom on your device. During the interview, the interviewer will ask you a variety of questions about sexual violence and intimate partner violence. Then the interviewer will ask you to explain what you were thinking as you answered the questions. The interviewer will also ask you about your opinions of the questions. Your answers will help us find out if the survey questions will be easy for other people to answer. NCHS secures all information we collect, process and store on our systems as required by Federal regulations, Executive Orders, and NCHS confidentiality statutes.  However, NCHS cannot secure and protect your personal computing devices, such as personal computer or smart phones, used to complete the NCHS interview.

With your permission, we would like to record your interview. The recording is a record of what we asked and what you said about the questions. Do you give permission to have your interview video recorded? [Yes/No] [If no, go to exit script 7. At a minimum video recording is essential for this project].

After we talk today, you will be sent a confirmation email with the date and time of your interview. Can we have your email address to send the confirmation email? [Get e-mail.] Attached with the confirmation email will be a consent form. In order to take part in the study you must read the entire consent form. The consent form tells you about the study and what you will be asked to do. If you have any questions about confidentiality, identity protection, procedures or other topics related to the study please contact me [name] at [phone number/email] any time before your interview.  

Do you have any questions at this point?  [Pause to answer questions].  If (not/you have no other questions), then let’s get you on the schedule, ok?  We will be interviewing (Day, Month/Date) through (Day, Month/Date) from (time to time).  Looking at your schedule, when would you be available to participate?  [Schedule.]  [If date/times not available go to exit script 8.]  

[If remuneration is cash] What is your mailing address?  We will use this address to send you $50 cash via FedEx after the completion of the interview.  Packages typically take 5 business days to arrive.  

 

[If remuneration is an electronic gift card] After your interview, we will email you the activation code for your $50 electronic gift card with a “thank you” letter. The email will be sent right after your interview, and you will be able to use your electronic gift card immediately after activation.

Do you have 5 minutes right now to set up Zoom on the device you will be using for the interview? If not, we can schedule another time to do it prior to the interview. 

 

We ask that you be in a quiet, private space, alone with minimal distractions during your interview. To protect your identity, we ask that no photos or personable identifiable items be visible during the interview. To minimize movement and distractions during the interview please place your device on a stable surface. 

 

A reminder call will be made to you a few days in advance.  Should you have any questions or need to change your appointment, please feel free to contact me [name] at [phone number]. Thank you for responding to our ad, and I look forward to seeing you through Zoom on (DATE/TIME) [Get respondent to cite date & time if possible.] 

Entry Script for interviews conducted onsite at NCHS or off-site:

...Based on your answers to the questions so far, we would like you to take part in our study. For this study we’d like you to come here to the National Center for Health Statistics in Hyattsville, Maryland/agreed mutual location. An interviewer will ask you to fill out a questionnaire about sexual violence and intimate partner violence. Then the interviewer will ask you to explain what you were thinking as you answered the questions. The interviewer will also ask you about your opinions of the questions. Your answers will help us find out if the survey questions will be easy for other people to answer. Everything you say will be kept private. With your permission, we would like to record your interview. The recording is a record of what we asked and what you said about the questions. Do you give permission to have your interview video recorded? [Yes/No] [If no, ask if for permission to audio record]. Do you give permission to have your interview audio recorded? [Yes/No] [If no, go to exit script 7. At a minimum audio recording is essential for this project].

Do you have any questions at this point? [Pause to answer questions.] If (not/you have no other questions), then let’s get you on the schedule, ok? We will be interviewing (Day, Month/Date) through (Day, Month/Date) from 8 a.m. to 6 p.m. Looking at your schedule, when would you be available to participate? [Schedule.] [If date/times not available go to exit script 8.]

A reminder call will be made to you a few days in advance. Should you have any questions or need to change your appointment, please feel free to contact me [name] at [phone number]. Thank you for responding to our ad, and I look forward to seeing you here at (DATE/TIME) [Get respondent to cite date & time if possible.]

---------------------------------------------------------

Exit script 1: I see...ok. Would it be okay if I kept your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? Your information will be kept for up to 5 years and you can decide at any time to be removed from our database. Email [email protected] to request removal. [If yes, keep in database. If no:] OK, thank you for your time. Your name and any information you gave me will be deleted from our database.

Exit script 2: I’m sorry, you have to be 18 years of age or older to take part in this study and therefore we won’t be able to use you at this time. We appreciate your call and thank you for your interest in our study.

Exit script 3: I’m sorry, you have not met one of the eligibility requirements for this particular study. Would it be okay if I kept your name, telephone number, age, educational level, and race in our database so that I can contact you about other studies coming up in the future? Your information will be kept for up to 5 years and you can decide at any time to be removed from our database. Email [email protected] to request removal.. [If yes, keep in database. If no:] OK, thank you for your time. Your name and any information you gave me will be deleted from our database.

Exit Script 4: Based upon your answers, it seems that we may already have a number of volunteers with very similar answers to yours. At this point we need to talk with people with some different characteristics. However, if we have cancellations or other slots open up, I may wish to call you back. Would it be okay if I kept your name, telephone number, and the information you provided in response to the eligibility questions until the end of this study? [ If yes,] make notation. [If no,] would it be okay if I kept your name, telephone number, age, educational level, and race in our database so that I can contact you about other studies coming up in the future? Your information will be kept for up to 5 years and you can decide at any time to be removed from our database. Email [email protected] to request removal. [If yes, keep in database. If no:] OK, thank you for your time. Your name and any information you gave me will be deleted from our database.

Exit script 5: I’m sorry, all Federal Government facilities require screening procedures for non-U.S. citizens. This process can take more than 30 days. Unfortunately, our study has to be completed before your screening process would be complete. Would you be agreeable to having your interview conducted at an offsite location? [If yes,] discuss off-site interviewing locations. [If no], would it be okay if I kept your name, telephone number, age, educational level, and race in our database so that I can contact you about other studies coming up in the future? Your information will be kept for up to 5 years and you can decide at any time to be removed from our database. Email [email protected] to request removal. [If yes, keep in database. If no:] OK, thank you for your time. Your name and any information you gave me will be deleted from our database.

Exit script 6: I’m sorry, these interviews will be conducted over video chat, and you need a computer, tablet or cellphone with internet to participate; therefore, we won’t be able to schedule you at this time. Would it be okay if I added your name, telephone number, age, educational level, and race to our database so that I can contact you about other studies coming up in the future? Your information will be kept for up to 5 years and you can decide at any time to be removed from our database. Email [email protected] to request removal. [If yes, add to database. If no:] OK, thank you for your time. Your name and any information you gave me will not be added to our database.

Exit script 7: I’m sorry, willingness to be [FOR VIRTUAL: video/ FOR INTERVIEWS TO BE CONDUCTED AT NCHS: audio] recorded is required in order to take part in this study and therefore we won’t be able to use you at this time. Would it be okay if I kept your name, telephone number, age, educational level, and race in our database so that I can contact you about other studies coming up in the future? Your information will be kept for up to 5 years and you can decide at any time to be removed from our database. Email [email protected] to request removal. [If yes, keep in database. If no:] OK, thank you for your time. Your name and any information you gave me will be deleted from our database.

Exit script 8: I see...ok, we were hoping to complete this particular study between (Month/Date) and (Month/Date), so it looks like we won’t be able to schedule you at this time. Would it be okay if I kept your name, telephone number, age, educational level, and race in our database so that I can contact you about other studies coming up in the future? Your information will be kept for up to 5 years and you can decide at any time to be removed from our database. Email [email protected] to request removal. [If yes, keep in database. If no:] OK, thank you for your time. Your name and any information you gave me will be deleted from our database.