Form no number no number Focus Group Screener

Attachment D: Focus Group Screener

Form Approved

OMB Control No. _________

Expiration Date _________

Focus Group Screener

Hello, I’m _______________ with _____________________, an independent consumer research firm. We are not selling or promoting any product or service. We are conducting a research study with people who are involved with health and safety in workplaces. Everyone who participates in these discussions will receive $75.00. I would like to ask you some questions to see if you qualify for one of the discussion groups. These questions will only take a few moments to answer. The groups will be held at [times] on [date] at [location] and will last about two hours. Refreshments will be served. Do you have time now to answer a few questions?

Recruit 12 to seat 9 respondents in the room

1. In your workplace, are you responsible for monitoring or ensuring workplace safety or health?

( ) Yes Continue

( ) No Terminate

NOTE: Use the following language to “terminate” call throughout screening process:

“Thank you for taking the time to answer our questions. Unfortunately, the category you fall into is currently full. If it should open back up, may we call you back?”

2. What industry do you work in?

___________________________________(Record) Continue

Recruit a mix

3. What is your job title?

___________________________________(Record) Continue

Recruit a mix

Public reporting burden for this collection of information is estimated to average 15 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: Maryam Daneshvar, CDC Acting Reports Clearance Officer, 1600 Clifton Road, MS-D74, Atlanta, GA 30333.

4. Approximately how many people are employed by your organization?

( ) less than 10 Terminate

( ) 10-50 Continue

( ) 51-100 Continue

( ) 101-250 Continue

( ) more than 250 Terminate

5. Have you or anyone in your home worked in or retired from any of the following industries?

(Read and record response)

( ) Marketing or public relations Terminate

( ) Advertising Terminate

( ) Market research Terminate

( ) None of the above Continue

6. Have you ever participated in a market research study, in which you were paid $20 or more to provide your opinions regarding a product, a service, or advertising?

( ) Yes Continue to 6a

( ) No Continue to 7

Recruit a mix

6a. How many of these studies have you participated in?

(Record response)

Terminate if 5 or more

6b. Have you participated in one of these studies within the last 6 months?

(Record response)

( ) Yes Terminate

( ) No Continue

Terminate if 6 months ago or less

7. So that we can be sure that all backgrounds are represented in our study, please tell me your race or ethnic origin. Are you . . . ?

( ) Black or African American Continue

( ) White Continue

( ) Hispanic or Latino Continue

( ) Asian Continue

( ) American Indian or Alaska Native Continue

( ) Native Hawaiian or Other Pacific Islander Continue

Recruit no more than half Caucasian

8. Which of the following best describes your age?

( ) 18-30 Continue

( ) 31-45 Continue

( ) 46-60 Continue

( ) 60 or older Continue

Recruit a mix

9. Are you employed full or part-time?

( ) Full time Continue

( ) Part-time Continue

Recruit a majority employed full-time

10. Which of the following best describes your education?

( ) Less than high school degree Continue

( ) High school degree Continue

( ) Trade or technical school Continue

( ) Some college Continue

( ) College degree Continue

( ) Graduate degree Continue

Recruit a mix

11. Finally, can you think of a resource related to workplace health or safety that you used lately? Can you tell me something about it and what you think of it?

Record resource name _________________________________________

Note to recruiter: This question is intended to establish whether the respondent is reasonably articulate, fluent in English, willing to converse and easy to understand. If respondent has trouble communicating (e.g., “shuts down”) or can not be easily understood, thank and terminate.

Thank you for answering my questions. As I mentioned earlier, we are conducting a research study regarding workplace health and safety and would like to hear your views. In order to hear them first-hand, we are conducting an informal, round-table discussion to be held on [Date] at [Time]. The discussion will last about 2 hours and will be both fun and informative. No one will try to sell you anything, and no one will call on you as a result of your participation. You will receive $75.00 to compensate you for any expenses. This is an important project, and we hope that you will be part of it. We can only invite about a dozen people to take part. Can we schedule your attendance?

During the session we will be reviewing some printed (written) materials regarding workplace health hazards. Would you be comfortable reading through the materials and discussing them in a group situation?

Please be sure to arrive about 15 minutes early, so that you’ll have time to review some materials before your meeting. Please be sure to contact us as soon as possible if something comes up and you can't attend. (Give Phone Number). Also, if you need glasses for reading please be sure to bring them. Before we hang up, let me get the correct spelling of your name, and your address and phone numbers so we can send you a confirmation letter with directions to our facility and give you a call to remind you about the focus group discussion.

NAME______________________________

HOME PHONE______________________

ADDRESS ____________________________________________

____________________________________________

WORK PHONE____________CELL PHONE _________

E-MAIL