Couples -screener

Attachment 7

Screening Questionnaire for Couples

READ BELOW TO BOTH MEMBERS OF COUPLE

Thank you very much for speaking with us about the interviews we are conducting. My name is _________ and I work for Schlesinger Associates. We are working with RTI International and the Centers for Disease Control and Prevention (CDC) to recruit couples to participate in telephone interviews together to examine how women and their partners work together and communicate about women’s health and healthy behaviors.

Couples who are qualified to participate will be asked to take part in a one-time, telephone interview for approximately 60 minutes. The interview will be audio recorded and it is possible that someone from the CDC would be listening during the interview. After completion of the discussion, you and your spouse or partner will each receive $35 in appreciation of your time. Participation is completely voluntary. All information you provide will remain secure.

Does this sound like something you would be interested in participating in?

[If NO] Thank you for your time.

[If YES] Great. Would it be okay if I ask you a few questions? Some of the questions may make you feel uncomfortable, but your decision to answer the questions is completely voluntary and you can skip any question you do not feel comfortable answering and stop answering questions at any time.

IF SPEAK WITH FEMALE PARTICIPANT FIRST, START AT QUESTION 1.

IF SPEAK WITH MALE PARTICIPANT FIRST, START AT QUESTION 18.

1. What is your age? ______________ years

If age is 18-44 years CONTINUE

If age is less than 18 years or greater than 44 years TERMINATE

2. Are you currently married or in a committed relationship?

Yes, Married SKIP TO Q4

Yes, Committed Relationship GO TO Q3

No TERMINATE

3. Do you and your partner live together at the same address?

Yes

No

4. How long have you been [married or in a committed relationship]?

_____________ years

5. Are you comfortable participating in a 60-minute telephone interview together with your spouse or partner in English?

Yes

No TERMINATE

6. Which of the following categories best describes your income (before taxes) from all sources in 2009?

Less than $35,000 (LOW)

Between $35,000 and $75,000 (HIGH)

$75,000 or more TERMINATE

Don’t know TERMINATE

7. What is the highest grade or year of school you completed?

Never attended school

Grades 1 through 8

Grade 9 through 11 (some high school) (LOW)

Grade 12 or GED (high school graduate)

College 1-3 years (some college or technical school)

College 4 years or more (college graduate) (HIGH)

8. Are you currently covered by health insurance or some other kind of health care plan?

Yes

No (SKIP TO QUESTION 10; LOW)

9. What kind of health insurance or health care plan or coverage do you have? (Check all that apply.)

Medicaid (LOW)

State-Sponsored Health Plan

Private or employer health insurance plan

Military Health Care/VA (HIGH)

Other, please specify: _________________________________

10. How many biological children do you and your spouse or partner have together?

______ IF 0, GO TO Q12.

11. How old is your child/children?

Child 1 ___________ Child 4___________

Child 2 ___________ Child 5____________

Child 3___________

12. Have you given birth in the past 12 months?

Yes SKIP TO QUESTION 15 (INCLUDE IN GROUP 5)

No

13. Are you currently pregnant?

Yes TERMINATE

No

14. Which of the following statements would best describe you and your spouse or partner?

We are planning for a pregnancy in the next year or so

(0 kids = INCLUDE IN GROUP 1; 1+ kids = INCLUDE IN GROUP 2)

We are not planning a pregnancy in the next year or so but plan to try getting pregnant at some time in the future

(0 kids = INCLUDE IN GROUP 1; 1+ kids = INCLUDE IN GROUP 2)

We do not plan a pregnancy at any time in the future

(0 kids = INCLUDE IN GROUP 3; 1+ kids = INCLUDE IN GROUP 4)

We cannot get pregnant (surgical sterilization, tubal ligation, hysterectomy, vasectomy, sterility, infertility) TERMINATE

15. Are you Hispanic or Latina?

Yes

No

16. Which of the following categories describes your race? [EXPLAIN THAT THEY CAN SELECT ALL THAT APPLY]

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

17. What is your current employment status?

Working full time for pay

Working part time for pay

Full-time homemaker or family caregiver

Retired

Unemployed

Student

Other, please specify: _________________________________

I have some questions that I’d like to ask your spouse (or partner). Would s/he be available to speak with now?

Yes

No [get time to call back]

Questions for Male Participant

[READ INTRODUCTION ON PAGE 1 IF HAVE NOT ALREADY]

18. What is your age? ______________ years

19. Are you comfortable participating in a 60-minute telephone interview together with your spouse or partner in English?

Yes CONTINUE

No TERMINATE

24. Which of the following categories best describes your income (before taxes) from all sources in 2009?

Less than $35,000 (LOW)

Between $35,000 and $75,000 (HIGH)

$75,000 or more TERMINATE **ONLY IF TALK WITH

Don’t know TERMINATE MALE FIRST**

25. What is the highest grade or year of school you have completed?

Never attended school

Grades 1 through 8

Grade 9 through 11 (some high school)

Grade 12 or GED (high school graduate)

College 1-3 years (some college or technical school)

College 4 years or more (college graduate)

20. How many biological children do you and your spouse or partner have together?

______

21. How old is your child/children?

Child 1 ___________ Child 4___________

Child 2 ___________ Child 5____________

Child 3___________

22. Are you Hispanic or Latino?

Yes

No

23. Which of the following categories describes your race? [EXPLAIN THAT THEY CAN SELECT ALL THAT APPLY]

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

26. What is your current employment status?

Working full time for pay

Working part time for pay

Full-time homemaker or family caregiver

Retired

Unemployed

Student

Other, please specify: _________________________________

____________________________________________________________________________

WRAP-UP FOR TERMINATED INDIVIDUALS:

Thank you for speaking with us and answering the questions today, but unfortunately you are not eligible to participate in a telephone interview examining communication about women’s health and healthy behaviors. All information that you provided today will remain secure. If you have any further questions about this project please call XXX-XXX-XXXX. Thank you again.

_____________________________________________________________________________

CATEGORIZING ELIGIBLE COUPLES

Income	Insurance	Education	GROUP
LOW	LOW	LOW	GROUP A
LOW	HIGH	HIGH	GROUP B
LOW	LOW	HIGH	GROUP A
HIGH	LOW	LOW	GROUP A
HIGH	HIGH	LOW	GROUP A
HIGH	HIGH	HIGH	GROUP B

WRAP-UP FOR ELIGIBLE COUPLES:

Group Eligibility (Check appropriate box):

		A (see above)	B (see above)
	Couples who have not had a child and plan to be pregnant
	Couples who have had children (more than a year ago or more) and plan to have more children
	Couples who do not plan to have children
	Couples who have had children (more than a year ago or more) and are not planning to have more
	Couples who have had a baby in the last year (irrespective of their future pregnancy plans)

Schedule for Interview:

I would like to invite you to participate in a telephone interview that will be held on [DAY] at [TIME]. During that time, you will be asked to call into a toll-free telephone line and a trained interviewer from RTI International will lead the discussion with you and your partner/spouse. As I mentioned earlier, the discussion will last approximately 60 minutes. To thank you for your time, you and your spouse/partner will each receive $35 following your participation in the discussion. Would you be willing to participate?

Yes GET CONTACT INFO

No END CALL

I would like to ask you for some contact information so that I may be able to send you a confirmation letter for your scheduled interview. Your name and address will not be given to anyone.

Female Participant contact information:

Respondent’s name: ___________________________________________

Address: ____________________________________________________

Telephone #: (Home) __________________ (Work/Cell) _________________

(Pager)____________________

Email address: ________________________________________________

Male Partner Contact Information:

Respondent’s name: ___________________________________________

Address: ____________________________________________________

Telephone #: (Home) __________________ (Work/Cell) _________________

(Pager)____________________

Email address: ________________________________________________

We will send you a confirmation letter shortly providing you with information on the date, time and location of the study. Please call XXX-XXX-XXXX if you have any questions.

Recruitment Grid

Recruitment Grid for Project 2 Couple Interview

Last Name, First Name	Date and Time	Q.1 Age	Q.6 Income Level Low OR High	Q. 7 Education Level Low OR High	Q. 8,9 Health Insurance Low OR HIGH	Q. 12, 14 Pregnancy Planning Status (1-5) 1. Couples who have not had a child and plan to be pregnant 2. Couples who have had children (more than a year ago or more) and plan to have more children 3. Couples who do not plan to have children 4. Couples who have had children (more than a year ago or more) and are not planning to have more 5. Couples who have had a baby in the last year (irrespective of their future pregnancy plans)
1
2
3
4
5
6
7
8
9
10

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