Women consumers - Screener

Attachment 6

Screening Questionnaire for Consumers

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 women to participate in a focus group discussions to examine views about women’s health and healthy behaviors.

People who are qualified to participate will be asked to take part in a one-time, in-person focus group for approximately 90 minutes. The group discussion will be audio recorded. After completion of the discussion, you will receive $75 in appreciation of your time. Participation is completely voluntary. Any 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 skip any question you do not feel comfortable answering and stop answering questions at any time.

1. What is your age? ______________ years

18-44 CONTINUE

Other TERMINATE

2. Are you comfortable with participating in a 90-minute discussion in English?

Yes CONTINUE

No TERMINATE

Questions 3 – 5 will are used to categorize SES groups.

Income	Insurance	Education	GROUP
LOW	LOW	LOW	GROUP A
<30k	No insurance	Never
	Medicaid	1-9
	SCHIP	9-11
	Other public	12/GED
LOW	HIGH	HIGH	GROUP B
<30k	Private	1-3 college
	Military/tricare	College grad
	Other
LOW	LOW	HIGH	GROUP A
<30k	No insurance	1-3 college
	Medicaid	College grad
	SCHIP
	Other public
HIGH	LOW	LOW	GROUP A
30-75k	No insurance	Never
	Medicaid	1-9
	SCHIP	9-11
	Other public	12/GED
HIGH	HIGH	LOW	GROUP A
30-75k	Private	Never
	Military/Tricare	1-9
	Other	9-11
		12/GED
HIGH	HIGH	HIGH	GROUP B
30-75k	Private	1-3 college
	Military/tricare	College grad
	Other

3. Which of the following categories best describes your total family income (before taxes) from all sources in 2008?

Less than $30,000

Between $30,000 and $75,000

More than $75,000 TERMINATE

Don’t know TERMINATE

4. Do you have health insurance?

Yes Go to Question 4a

No Go to Question 5

4a. What type of insurance program or health plan do you have?

• Private Insurance Plan through employer or self pay......

• Military/TRICARE....................................

• Medicaid.....................................................................

• SCHIP [to be filled in by appropriate state name].........

• Other Public Program..................................................

• Other ____________________________

5. 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)

Grade 12 or GED (high school graduate)

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

College 4 years or more (college graduate)

6. What is your current marital status?

Married or in a committed relationship

Divorced

Separated

Widowed

Single (never married)

The next questions are used to determine five reproductive planning-related groups:

Group 1: Women who have not had a child and want to be pregnant

Group 2: Women who have had children (more than a year ago or more) and want to have more children

Group 3: Women who do not want to have children

Group 4: Women who have had children (more than a year ago or more) and are not planning to have more

Group 5: Women who have had a baby in the last year (irrespective of their future pregnancy plans)

7. How many biological children do you have? ______ IF 0, GO TO Q 9.

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

Yes SKIP TO QUESTION 10 (INCLUDE IN GROUP 5)

No GO TO QUESTION 9

9. Are you currently pregnant?

Yes TERMINATE

No GO TO QUESTION Q10

10. Which of the following statements would best describe you?

I am planning to get pregnant in the next year or so CONTINUE

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

I am not planning a pregnancy in the next year or so but I plan to at some time in the future CONTINUE

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

I do not plan to get pregnant at any time in the future CONTINUE

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

I cannot get pregnant (surgical sterilization, tubal ligation, hysterectomy, infertility) TERMINATE

11. Are you Hispanic or Latino?

Yes

No

12. 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

_____________________________________________________________________________

WRAP-UP FOR TERMINATED INDIVIDUALS:

Section 1Thank you for speaking with us and answering the questions today, but unfortunately you are not eligible to participate in the focus group discussions. 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.

_____________________________________________________________________________

WRAP-UP FOR ELIGIBLE INDIVIDUALS:

Group Eligibility (Check appropriate box):

		A (No or limited health insurance; lower education and income)	B (Health insurance; middle income & education)
	Women who have not had a child and want to be pregnant
	Women who have had children (more than a year ago or more) and want to have more children
	Women who do not want to have children
	Women who have had children (more than a year ago or more) and are not planning to have more
	Women who have had a baby in the last year (irrespective of their future pregnancy plans)

Schedule for Focus Group:

I would like to invite you to participate focus group discussion that will be held on [DAY] at [TIME]. The group discussion will be held at [NAME OF SITE/ADDRESS]. As I mentioned earlier, the discussion will last approximately 90 minutes. Child care will be provided on site if needed. To thank you for your time, you will receive $75 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. 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 consumers

Last Name, First Name	Date and Time	Q1. Age	Q3-Q5. SES (Income, Insurance, Education) GROUP A Or GROUP B	Q3. Income Low OR Middle	Q. 3, 4 Health Insurance NONE / LIMITED OR INSURED	Q. 5 Education Level < HS OR >SOME COLLEGE	Reproductive Planning Groups Status (1-5) 1. Women who have not had a child and plan to be pregnant 2. Women who have had children (more than a year ago or more) and plan to have more children 3. Women who do not plan to have children 4. Women who have had children (more than a year ago or more) and are not planning to have more 5. Women who have had a baby in the last year (irrespective of their future pregnancy plans)	Q. 11 Hispanic/ Latina No OR Yes	Q. 12 Race White Black Am. Indian/ Alaska Nat. Asian Nat Haw/Other Pacific Islander
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