Screener for Primary Pre and Post Campaign Survey

APPENDIX D1

Baseline and Immediate Post Intervention Screener

Form Approved

OMB No. 0920-XXXX

Expiration Date XX/XX/XXXX

Centers for Disease Control and Prevention ARTHRITIS PROGRAM

Evaluation of the Spanish language campaign

“Good Morning Arthritis. Today you will not defeat us.”

Pre- and Post Campaign Data Collection Screener

Public Reporting Burden Statement

Public reporting burden of this collection of information is an estimated average of 2 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: OMB 0920-XXXX

SCREENING/QUALIFICATION QUESTIONS

[INTRODUCTION] Hello. My name is _________________, and I'm calling on behalf of CDC (Centers for Disease Control and Prevention). We are conducting a survey today about people’s health and would like to include your opinions. We are not selling anything, but are simply interested in your ideas and opinions. The survey will only take about 15 minutes total.

To protect your identity and encourage open and honest responses to the questions in our survey, please let me reassure you that we are calling people randomly today, and I have no record of your name or phone number. Your answers to our questions will be grouped together with the answers of other individuals in your area in an anonymous manner.  As such, I want to encourage you to be as open and honest as you can be in answering our questions today.  Please also feel free to skip any questions.

Jed: how can we say we don’t keep name of phone?

Because we are surveying people of different ages today, may I ask what is your exact age? [DO NOT READ LIST; FILL IN RANGE WITH EXACT AGE]

Exact Age: _________ [RESPONDENT MUST BE 45-64 YRS. TO CONTINUE]

[IF RESPONDENT IS NOT BETWEEN 45-64 YRS, ASK IF THERE IS ANYONE ELSE LIVING IN THE HOUSEHOLD WHO IS BETWEEN THE AGES OF 45-64. IF NOT, THANK AND END.]

Under 45	1	[THANK & END]
45 – 54	2	[SAMPLE SHOULD BE ½ 45-54 AND ½ 55-64]
55 – 64	3
65 +	4	[THANK & END FOR CODES 4, 77 & 88]
Don’t know	77
Refused	88

Which one of these groups would you say best represents your race? [READ LIST. RECORD ONE RESPONSE.]

White	1
Black or African American or	2
Asian	3
Native Hawaiian or other Pacific Islander	4
American Indian, Alaskan Native	5
Other	6
Refused	88

2a. Are you Hispanic or Latino?

Yes	1	[CONTINUE FOR CODE 1, THANK & END FOR ALL OTHER CODES]
No	2

2b. What is your Hispanic or Latino ancestry or origin? Is it…

Mexican/Mexicano	1	Nicaraguan	8
Mexican American	2	Panamanian	9
Chicano	3	Puerto Rican	10
Salvadoran	4	Cuban	11
Guatemalan	5	Spanish-American	12
Costa Rican	6	Other Latino (specify)	13
Honduran	7	Other (specify)	14

What language do you speak most often at home?

Spanish	1	[CONTINUE]
English	2	[THANK & END FOR CODES 2-4, 88]
Other	3
Don’t know	4
Refused	88

Which of the following ranges best represents your household’s total annual income? [READ LIST.]

$35,000 or less	1	[CONTINUE]
More than $35,000	2	[THANK & END FOR CODES 4, 77 & 88]
Don’t know	77
Refused	88

5. [Record gender. DO NOT READ. IF UNCERTAIN, ASK, “ARE YOU MALE OR FEMALE?”]

Male	1	[SAMPLE SHOULD BE ½ MALE ½ FEMALE]
Female	2

5. As I mentioned earlier, we are surveying people in your area about their health. Have you EVER been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, Gout [“gowt”], Lupus [“LOO pus”], or Fibromyalgia [“fye bro my AL gee ah”]?

Yes	1	[TRACK]
No	2
Don’t know	77
Refused	88

5. The next few questions refer specifically to your joints. When thinking about your answer to each question, please do NOT include the back or neck. During the past 30 days, have you had any symptoms of pain, aching, or stiffness in or around a joint?

Yes	1	[CONTINUE]
No	2	[IF NO, DON’T KNOW, OR REFUSED TO Q.6, THANK AND END. OTHERWISE, SKIP TO Q.9]
Don’t know	77
Refused	88

[INTERVIEWER NOTE: IF NO, DK, OR REF TO Q.6 & Q.7, ASK, "Is there anyone else in your household between the ages of 45-64 and has symptoms of pain, aching, or stiffness in and around a joint?" IF YES, START NEW SURVEY.]

5. Did your joint symptoms first begin more than three months ago?

Yes [symptoms began more than three months ago]	1	[CONTINUE]
No [symptoms began less than three months ago]	2	[IF NO, DON’T KNOW, OR REFUSED TO Q.7, THANK & END.]
Don’t know	77	[THANK & END]
Refused	88

[RESPONDENT MUST EITHER RESPOND YES TO Q.6 OR YES TO Q.8 IN ORDER TO CONTINUE]

[version 10/31/07] Page 1