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Field Test - Screener
ICR 202512-0920-004 · OMB 0920-1061 · Object 164736900.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Field Test - Screener |
| Author | Pierannunzi, Carol (CDC/ONDIEH/NCCDPHP) |
| Last Modified By | Writer |
| File Modified | 2025-03-04 |
| File Created | 2026-09-13 |
| Conversion State | complete |
Extracted Text
Attachment 5: BRFSS Landline and Cell Phone Screening Scripts for Subject Recruitment ] Table of Contents OMB Header and Introductory Text 4 Landline Introduction 5 Cell Phone Introduction 11 OMB Header and Introductory Text Read if necessary Read Interviewer instructions (not read) Public reporting burden of this collection of information is estimated to average 27 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 D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1061). Form Approved OMB No. 0920-1061 Exp. Date 02/28/2025 Interviewers do not need to read any part of the burden estimate nor provide the OMB number unless asked by the respondent for specific information. If a respondent asks for the length of time of the interview provide the most accurate information based on the version of the questionnaire that will be administered to that respondent. If the interviewer is not sure, provide the average time as indicated in the burden statement. If data collectors have questions concerning the BRFSS OMB process, please contact Marquisette Glass Lewis at [email protected]. HELLO, I am calling for the [STATE OF xxx] Department of Health. My name is (name). We are gathering information about the health of US residents. This project is conducted by the health department with assistance from the Centers for Disease Control and Prevention. Your telephone number has been chosen randomly, and I would like to ask some questions about health and health practices. States may opt not to mention the state name to avoid refusals by out of state residents in the cell phone sample. If cell phone respondent objects to being contacted by state where they have never lived, say: “This survey is conducted by all states and your information will be forwarded to the correct state of residence” Landline Introduction Question Number Question text Variable names Responses (DO NOT READ UNLESS OTHERWISE NOTED) SKIP INFO/ CATI Note Interviewer Note (s) Column(s) LL01. Is this [PHONE NUMBER]? 1 Yes Go to LL02 2 No TERMINATE Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time. LL02. Is this a private residence? 1 Yes Go to LL04 Read if necessary: By private residence we mean someplace like a house or apartment. Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year. 2 No Go to LL03 If no, business phone only: thank you very much but we are only interviewing persons on residential phones lines at this time. NOTE: Business numbers which are also used for personal communication are eligible. 3 No, this is a business Read: Thank you very much but we are only interviewing persons on residential phones at this time. TERMINATE LL03. Do you live in college housing? 1 Yes Go to LL04 Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university. 2 No TERMINATE Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time. LL04. Do you currently live in__(state)____? 1 Yes Go to LL05 2 No TERMINATE Thank you very much but we are only interviewing persons who live in [STATE] at this time. LL05. Is this a cell phone? 1 Yes, it is a cell phone TERMINATE Read: Thank you very much but we are only interviewing by landline telephones in private residences or college housing at this time. 2 Not a cell phone Go to LL06 Read if necessary: By cell phone we mean a telephone that is mobile and usable outside your neighborhood. Do not read: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services). LL06. Are you 18 years of age or older? 1 Yes IF COLLEGE HOUSING (LL03) = “YES,” GO TO LL09; OTHERWISE GO TO NUMBER OF ADULTS LL07 2 No IF COLLEGE HOUSING (LL03) = “YES,” Terminate; OTHERWISE GO TO NUMBER OF ADULTS LL07 Read: Thank you very much but we are only interviewing persons aged 18 or older at this time. LL07. I need to randomly select one adult who lives in your household to be interviewed. Excluding adults living away from home, such as students away at college, how many members of your household, including yourself, are 18 years of age or older? 1 Go to LL09 Read: Are you that adult? If yes: Then you are the person I need to speak with. If no: May I speak with the adult in the household? 2-6 or more Go to LL08. If respondent questions why any specific individual was chosen, emphasize that the selection is random and is not limited to any certain age group or sex. LL08. The person in your household that I need to speak with is the adult with the most recent birthday. Are you the adult with the most recent birthday? 1 = Yes 2 = No - Ask for correct respondent If person indicates that they are not the selected respondent, ask for correct respondent and re-ask LL08. (See CATI programming) LL09. Are you? Read: 1 Male 2 Female We ask this question to determine which health related questions apply to each respondent. For example, males might be asked about prostate health issues. If LL09 = Missing then TERMINATE “Thank you for your time, your number may be selected for another survey in the future.” Transition to Section 1. I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will not be connected to any personal information If you have any questions about the survey, please call (give appropriate state telephone number). Do not read: Introductory text may be reread when selected respondent is reached. Do not read: The sentence “Any information you give me will not be connected to any personal information” may be replaced by “Any personal information that you provide will not be used to identify you.” If the state coordinator approves the change. Cell Phone Introduction Question Number Question text Variable names Responses (DO NOT READ UNLESS OTHERWISE NOTED) SKIP INFO/ CATI Note Interviewer Note (s) Column(s) CP01. Is this a safe time to talk with you? 1 Yes Go to CP02 2 No ([set appointment if possible]) TERMINATE] Thank you very much. We will call you back at a more convenient time. CP02. Is this [PHONE NUMBER]? 1 Yes Go to CP03 2 No TERMINATE Thank you very much, but I seem to have dialed the wrong number. It’s possible that your number may be called at a later time CP03. Is this a cell phone? 1 Yes Go to CP04 2 No TERMINATE If "no”: thank you very much, but we are only interviewing persons on cell telephones at this time CP04. Are you 18 years of age or older? 1 Yes Go to CP05. 2 No TERMINATE Read: Thank you very much but we are only interviewing persons aged 18 or older at this time. CP05. Are you? Please read: 1 Male 2 Female We ask this question to determine which health related questions apply to each respondent. For example, males might be asked about prostate health issues. If CP05 = Missing then TERMINATE. “Thank you for your time, your number may be selected for another survey in the future.” CP07. Do you live in a private residence? 1 Yes Go to CP09 Read if necessary: By private residence we mean someplace like a house or apartment Do not read: Private residence includes any home where the respondent spends at least 30 days including vacation homes, RVs or other locations in which the respondent lives for portions of the year. 2 No Go to CP08 CP08. Do you live in college housing? 1 Yes Go to CP09 Read if necessary: By college housing we mean dormitory, graduate student or visiting faculty housing, or other housing arrangement provided by a college or university. 2 No TERMINATE Read: Thank you very much, but we are only interviewing persons who live in private residences or college housing at this time. CP09. Do you currently live in___(state)____? 1 Yes Go to CP11 2 No Go to CP10 CP10. In what state do you currently live? 1 Alabama 2 Alaska 4 Arizona 5 Arkansas 6 California 8 Colorado 9 Connecticut 10 Delaware 11 District of Columbia 12 Florida 13 Georgia 15 Hawaii 16 Idaho 17 Illinois 18 Indiana 19 Iowa 20 Kansas 21 Kentucky 22 Louisiana 23 Maine 24 Maryland 25 Massachusetts 26 Michigan 27 Minnesota 28 Mississippi 29 Missouri 30 Montana 31 Nebraska 32 Nevada 33 New Hampshire 34 New Jersey 35 New Mexico 36 New York 37 North Carolina 38 North Dakota 39 Ohio 40 Oklahoma 41 Oregon 42 Pennsylvania 44 Rhode Island 45 South Carolina 46 South Dakota 47 Tennessee 48 Texas 49 Utah 50 Vermont 51 Virginia 53 Washington 54 West Virginia 55 Wisconsin 56 Wyoming 66 Guam 72 Puerto Rico 78 Virgin Islands 77 Live outside US and participating territories 99 Refused TERMINATE Read: Thank you very much, but we are only interviewing persons who live in the US. CP11. Do you also have a landline telephone in your home that is used to make and receive calls? 1 Yes 2 No 7 Don’t know/ Not sure 9 Refused Read if necessary: By landline telephone, we mean a regular telephone in your home that is used for making or receiving calls. Please include landline phones used for both business and personal use. CP12. How many members of your household, including yourself, are 18 years of age or older? _ _ Number 77 Don’t know/ Not sure 99 Refused If CP08 = yes then number of adults is automatically set to 1 Transition to section 1. I will not ask for your last name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Any information you give me will not be connected to any personal information. If you have any questions about the survey, please call (give appropriate state telephone number).