Attachment 17 - Updated Materials

Grantee
Recruitment Guidelines

GRANTEE RECRUITMENT GUIDELINES
SUGGESTED INTRODUCTION SCRIPT:
[ASK FOR CONTACT PERSON IDENTIFIED IN VERIFICATION CALL]
Hello, my name is ________________ and I’m calling on behalf of HRSA and the Bureau of
Primary Health Care about the Primary Health Care Patient Surveys. I’m calling from Research
Triangle Institute International, which has been contracted to conduct the patient surveys. I was
given your name as the person in your office that is the most knowledgeable about the health
center sites that your organization funds via Section 330 funding. I recently mailed study
information to you. I am calling today to discuss the surveys in more detail and answer any
questions that you may have regarding participation. Do you have time to talk with me now?
[THE FIRST CALL MAY LAST 10 MINUTES]. [IF NO]…I will be happy to call back at a time that
is more convenient for you. [SET UP APPOINTMENT DATE AND TIME]

THE FOLLOWING MUST BE DISCUSSED DURING THE INITIAL OR SUBSEQUENT CALLS:
1.

Give summary of the patient surveys. Include purpose and major tasks.
The purpose of these surveys is to obtain nationally representative data about the health
and health care needs of patients who received services at Section 330 funded health
centers. The national studies will provide policy makers and service providers with a
better understanding of the health problems and needs of these patients, their health
care utilization, and met and unmet needs.

2.

Clarify our request.
We are seeking permission from the grantees to collect data at a sample of their sites.
We are requesting information on their sites so that our statistician can select the
sample of sites. Each selected site will be asked to allow RTI to conduct one-on-one
private, personal interviews with patients who have used the site in the previous year
(approx XX interviews per grantee, X or X per site). Copies of the interview questions
are available for grantee review.

3.

Identify any perceived barriers to participation and work out plans to alleviate such
barriers.

4.

Discuss the approval process that is required at the Grantee level. Do they have an
IRB that will need to review this? If so, when is its next meeting? Do they have any other
Board that will need to review this? If so, when is its next meeting? Offer assistance in
obtaining study approval and/or gaining their cooperation. RTI must receive written
notification of approval, if applicable. Discuss and document local requirements for
obtaining informed consent from minors and proxies.

5.

Address concerns about patient protection. Protective measures for the patient
surveys include:
• informing respondents up front that some of the questions may be sensitive in nature
and that they have the right to refuse to answer any questions;
• reassuring all subjects that they are under no obligation to respond to the interview
and may terminate their participation at any time;

•
•
•
•
•

informing participants that their answers are private, and that their names will not be
associated with responses provided;
conducting the interviews in a private location;
reporting information obtained from the interviews only in summary form;
maintaining hard copies of the consent forms in a locked storage cabinet;
destroying hard copies of consent forms after they are no longer needed;

Obtain the following information for each eligible site associated with the Grantee. Eligible
sites are defined as follows :
• The site should participate in at least one of the four funding programs and must have been
operating under the grantee for at least 1 year.
• The site is not a school-based health center.
• The site is not a specialized clinic, excepting clinics providing OB/GYN services.
• The site does not provide services only through migrant and seasonal farmworker voucher
screening program.
Name of site__________________________________
Contact Information
Name_________________________________
Title___________________________________
Address________________________________
Phone_________________________________
Email__________________________________
Fax___________________________________
Populations served (Circle Yes or No)
Migrant or seasonal farmworkers
Yes / No
Homeless
Yes / No
Public Housing
Yes / No
Other (Community health)
Yes / No
Number or Percent of users by population type during 2008:
Migrant or seasonal farmworkers
Homeless
Public Housing
Other (Community Health)
______Total
Type of site (select one for Homeless Site only)
Fixed serving homeless and general population
Fixed serving homeless only
Mobile serving homeless and general population
Mobile serving homeless only
Language
___% Patients speaking Spanish only
___% Patients speaking other language; SPECIFY LANGUAGE_____________
6.

After grantee agrees to participate, ask this contact for suggested sequence for other
approvals/permissions. Specifically, are there approvals that must be acquired before
contacting the site or can we immediately make contact with the site?

7.

Discuss Letter of Agreement, if applicable.

Respondent Recruitment Script

Primary Health Care Patient Surveys
Respondent Recruitment Script

You have been invited to participate in an interview as part of an important research effort
being conducted by Research Triangle Institute and sponsored by the Bureau of Primary
Health Care. The interview asks about your health care experiences and some other topics.
If you are eligible to complete the survey, you will receive $25 in cash or a gift of equal
value as thanks for your participation.
Here is a brochure that provides information about the study.
If you are interested in participating, or have any questions, please read the brochure and
speak with the on-site RTI representative, _______________________________.
If the on-site RTI representative is not available and you would like to find out more
information about the study, I can set an appointment for you to speak with her/him.
We hope you will choose to participate.
Thank you!

Information to be Included as Part of a
Trifold Brochure

INFORMATION TO BE INCLUDED AS PART OF A TRIFOLD
BROCHURE (DESIGN IS IN PROGRESS)
Frequently Asked Questions About the Primary Health Care
Patient Surveys
What are the surveys about? What is the purpose?
RTI (Research Triangle Institute) International is conducting the Primary Health Care Patient Surveys.
The surveys are sponsored by the Bureau of Primary Health Care within the Health Resources and
Services Administration (HRSA). These surveys are about people who receive health care at health
centers like this one. The surveys will try to find out what kinds of health issues people who use the
health centers have and how well their needs are met. The surveys are not associated with any
immigration laws and the agency sponsoring the study is not associated with an immigration agency.

What is involved and how long will it take?
If you agree to participate, you will take part in an in person interview conducted by one of our
interviewers. We will conduct the interview in private at the health center or another convenient location.
All responses will be kept private. You may refuse to answer any question and you may also stop the
interview at any time.

What types of questions will be asked?
Questions about health care received, medical conditions, alcohol and drug use and health insurance will
be asked.

How long are the interviews?
The time varies, but interviews generally take 1 hour.

Will I be paid?
You will receive $25 cash or a gift of equal value for your participation. The form of payment has been
selected by this health center.

What about my privacy?
The information you provide will be private. We will create and use a number instead of your name to
identify your interview in the computer. This will prevent anyone from finding out what your answers
were. After you complete the interview, the interviewer will not be able to look at your answers again.
We will combine your information with information from all of the other participants to create group
statistics.

Why was I selected for this study?
RTI requested the cooperation of about 600 health centers to conduct this study. This health center has
agreed to participate. You have been randomly selected from this health centers’ patients to participate.

Why should I participate?

Your opinions and experiences are valuable. You represent thousands of others who receive similar care
and services. Information we gather through these surveys will provide policy makers and health centers
with a better understanding of how patients are being served and how to better serve patients at these
health centers.

Do I have to participate?
You do not have to participate in this survey or respond to any questions you do not want to answer. If
you choose not to participate it will not affect any services you or your family may receive at the health
center or any other programs.

What is the RTI International?
RTI International is a nonprofit company in Research Triangle Park, North Carolina. RTI conducts
research and provides services to local, state, and federal agencies.

I have more questions. Who can answer them?
If you have any questions about these studies, you may call FIELD DIRECTOR 1 NAME at
(XXX)XXX-XXXX or FIELD DIRECTOR 2 NAME at (XXX)XXX-XXXX. If you have any questions
about your rights as a study participant, you may call RTI’s Office of Research Protections toll-free at (1866-214-2043).

Informed Consent Form for
Adult Survey Participation

Informed Consent Form for Adult Survey Participation
Primary Health Care Patient Surveys

About the Surveys
The Primary Health Care Patient Surveys are research studies being conducted by RTI International. The
surveys are sponsored by the Bureau of Primary Health Care within the Health Resources and Services
Administration (HRSA). They are about people who receive health care at places like this health care
center. The surveys will try to find out what kinds of health problems people come to health centers with
and how well the health centers are meeting the needs of the people who use them. You are one of about
4,000 people that RTI has selected to participate.
Participation
If you agree to participate, you will be asked some questions about your health and the services that you
receive at this health care center. Some of the questions may be personal, such as questions about drug or
alcohol use and your feelings. There also may be questions about HIV/AIDS. Most of the questions are
about less sensitive things like health care received and whether you have certain health conditions like
asthma or diabetes. Some people will get a shorter interview, while others will take a bit longer. The
interview may last about an hour.
Voluntary Participation
You may choose whether or not you would like to participate. If you choose not to participate it will not
affect any services you may receive at the health center or from any other programs. If you do not want to
answer some of the questions you are asked, that is okay. If you decide not to finish the questions, that is
okay too. It is possible that some questions may make you uncomfortable or feel various emotions. If you
need to take a break at any time, just let me know.
Benefits
There are no direct benefits to you. However, you will be helping us learn more about the health needs of
people who use health centers like this one.
Compensation for Participation
If you participate, you will be provided with $25 cash or a gift of equal value to thank you for your time.
Risks of Study Participation
There are two risks involved in study participation. One risk is that the questions we ask might make you
feel uncomfortable or upset. If you feel uncomfortable or upset, you may ask the interviewer to take a
break or skip any of the questions. The other risk is that someone might find out what you tell us during
the interview. To avoid that, we will do the interview in private where no one can hear your answers. We
will also create and use a number instead of your name to identify your interview. This will prevent
anyone from finding out what your answers were.
Your Privacy
Anything you tell me is private. The privacy of your answers is very important, so let me say a little more
about it. I am going to enter your answers into this computer. As mentioned, your answers will be linked
to a number instead of your name so no one else will know how you answered the questions. Everyone
involved in this research has signed an agreement stating they will protect the privacy of the information
you provide. The information that you tell me will not be shared with anyone at this health care center.

Exceptions to Privacy Pledge
There is one important exception to this promise of privacy. If I learn during our talk that your life, or
another person’s life or health could be in danger, I am required to tell the clinic staff or the proper
authorities.
Questions
If you have any questions about these studies, you may call FIELD DIRECTOR 1 NAME at
(XXX)XXX-XXXX or FIELD DIRECTOR 2 NAME at (XXX)XXX-XXXX. If you have any questions
about your rights as a study participant, you may call RTI’s Office of Research Protections toll-free at (1866-214-2043).
Do you have any questions that might help you decide whether or not you want to participate in the
study?
By signing below, you are agreeing to participate. Please sign only if:
9 You understand the information about the research described in this consent form,
9 You have had all of your questions answered fully, and
9 You want to participate.
You will be given a copy of this consent form to keep.
Respondent’s Signature: ___________________________________________ Date: _________
Interviewer’s Signature: ___________________________________________ Date: _________
Recordings
We are using a special quality control system on this project. The system runs on the computer and will
record what we say to each other during several different parts of the interview. Neither of us will know
when the computer is recording what we say. The recording will be reviewed by people at RTI to
monitor my work, and will be kept private. You may participate in the interview even if you do not
consent to the recordings. May we use this quality control system during your interview?
By signing below, you are agreeing we may use this quality control system.
Respondent’s Signature: ___________________________________________ Date: ________

Informed Consent Form for Parent/Guardian
Participation in Proxy Interview for
Accompanied Children

Informed Consent Form for Parent/Guardian
Participation in Proxy Interview for Accompanied Children
Primary Health Care Patient Surveys

About the Surveys
The Primary Health Care Patient Surveys are research studies that are being conducted by RTI
International. The surveys are sponsored by the Bureau of Primary Health Care within the Health
Resources and Services Administration (HRSA). They are about people who receive health care at places
like this health care center. The surveys will try to find out what kinds of health problems or questions
people come to health centers with and how well the health centers are meeting the needs of the people
who use them. Your child, CHILD’S NAME, is one of about 4,000 people that RTI has selected to be
included. Because CHILD’S NAME is less than 13 years old, we would like to ask you to answer
questions about his/her health and the services that he/she receives at this health care center.
Participation
If you agree to participate, you will be asked some questions about your child’s health and the services
that he/she receives at this health center. Some of the questions may be personal, such as questions about
your child's feelings. Most of the questions, however, are about less sensitive things like whether or not
your child has certain health conditions like asthma or diabetes. Some people will get a shorter interview,
while others will take a bit longer. The interview may last about an hour.
Voluntary Participation
You may choose whether or not you would like to participate. If you choose not to participate it will not
affect any services your child or your family may receive at the health center or from any other programs.
If you do not want to answer some of the questions you are asked, that is okay. If you decide not to finish
the questions, that is okay too. It is possible that some questions may make you uncomfortable or feel
various emotions. If you need to take a break at any time, just let me know.
Benefits
There are no direct benefits to you. However, you will be helping us learn more about the health needs of
people who use health centers like this one.
Compensation for Participation
In addition, if you participate, you will be provided with $25 cash or a gift of equal value to thank you for
your time.
Risks of Study Participation
There are two risks involved in study participation. One risk is that the questions we ask might make you
feel uncomfortable or upset. If you feel uncomfortable or upset, you may ask the interviewer to take a
break or to skip any of the questions. The other risk is that someone might find out what you tell us
during the interview. To avoid that, we will do the interview in private where no one can hear your
answers. We will also create and use a number instead of your name to identify your interview in the
computer. This will prevent anyone from finding out what your answers were.
Your Privacy
Anything you tell me is private. The privacy of your answers is very important, so let me say a little more
about it. I am going to enter your answers into this computer. As mentioned, your answers will be linked
to a number instead of your name so no one else will know how you answered the questions. Everyone
involved in this research has signed an agreement stating they will protect the privacy of the information
you provide. The information that you tell me will not be shared with anyone at this health care center.

Exceptions to Privacy Pledge
There is one important exception to this promise of privacy. If I learn during our talk that your child’s life
or health, or another person’s life or health could be in danger, I am required to inform the clinic staff or
the proper authorities.
Questions
If you have any questions about these studies, you may call FIELD DIRECTOR 1 NAME at
(XXX)XXX-XXXX or FIELD DIRECTOR 2 NAME at (XXX)XXX-XXXX. If you have any questions
about your rights as a study participant, you may call RTI’s Office of Research Protections toll-free at (1866-214-2043).
Do you have any questions that might help you decide whether or not you want to participate in the
study?
By signing below, you are agreeing to participate. Please sign only if:
9 You understand the information about the research described in this consent form,
9 You have had all of your questions answered fully, and
9 You want to participate.
You will be given a copy of this consent form to keep.
Respondent’s Signature: ___________________________________________ Date: _________
Interviewer’s Signature: ___________________________________________ Date: _________
Recordings
We are using a special quality control system on this project. The system runs on the computer and will
record what we say during several different parts of the interview. Neither of us will know when the
computer is recording what we say. The recording will be reviewed by people at RTI to monitor my
work, and will be kept private. You may participate in the interview even if you do not consent to the
recordings. May we use this quality control system during your interview?
By signing below, you are agreeing we may use this quality control system.
Respondent’s Signature: ___________________________________________ Date: _________

Parent/Guardian Permission Form for
Accompanied Adolescent (Ages 13–17) Survey
Participation

Parent/Guardian Permission Form for
Accompanied Adolescent (Ages 13–17) Survey Participation
Primary Health Care Patient Surveys

About the Surveys
The Primary Health Care Patient Surveys are research studies being conducted by RTI International. The
surveys are sponsored by the Bureau of Primary Health Care within the Health Resources and Services
Administration (HRSA). They are about people who receive health care at places like this health care
center. The surveys will try to find out what kinds of health problems people come to health centers with
and how well the health centers are meeting the needs of the people who use them. Your child is one of
about 4,000 people that RTI has selected to participate.
Participation
If your child agrees to participate, he/she will be asked some questions about his/her health and the
services that he/she receives at this health center. Some of the questions may be personal, such as
questions about your child's drug or alcohol use and his/her feelings. Most of the questions are about less
sensitive things like health care received and whether or not your child has certain health conditions like
asthma or diabetes. Some people will get a shorter interview, while others will take a bit longer. The
interview may last about an hour.
Voluntary Participation
Your child may choose whether or not he/she would like to participate. If you choose not to give us
permission or if your child chooses not to participate, it will not affect any services your child or your
family may receive at the health center or from any other programs. If your child does not want to answer
some of the questions he/she is asked, that is okay. If your child decides not to finish the questions, that is
okay too. It is possible that some questions may make your child uncomfortable or feel various emotions.
If he/she needs to take a break at any time, he/she should just let me know.
Benefits
There are not any direct benefits to your child. However, your child will be helping us learn more about
the health needs of people who use health centers like this one.
Compensation for Participation
In addition, if your child participates, he/she will be provided with $25 cash or a gift of equal value to
thank him/her for his/her time.
Risks of Study Participation
There are two risks involved in study participation. One risk is that the questions we ask might make your
child feel uncomfortable or upset. If your child feels uncomfortable or upset during the interview, he/she
may ask the interviewer to take a break or to skip any of the questions. The other risk is that someone
might find out what your child told us during the interview. To avoid that, we will do the interview in
private where no one can hear his/her answers. We will create and use a number instead of your child’s
name to identify your child’s interview in the computer. This will prevent anyone from finding out what
your child’s answers were.
Your Child’s Privacy
Anything your child tells me is private. The privacy of his/her answers is very important, so let me say a
little more about it. I am going to enter your child’s answers into this computer. As mentioned, his/her

answers will be linked to a number instead of his/her name so no one else will know how he/she answered
the questions. Everyone involved in this research has signed an agreement stating they will protect the
privacy of the information your child provides. The information that your child tells me will not be
shared with you or anyone at this health center.
Exceptions to Privacy Pledge
There is one important exception to this promise of privacy. If I learn during my talk with your child that
his/her life or health, or another person’s life or health could be in danger, I am required to inform the
clinic staff or the proper authorities.
Questions
If you have any questions about these studies, you may call FIELD DIRECTOR 1 NAME at
(XXX)XXX-XXXX or FIELD DIRECTOR 2 NAME at (XXX)XXX-XXXX. If you have any questions
about your child’s rights as a study participant, you may call RTI’s Office of Research Protections tollfree at (1-866-214-2043).
Do you have any questions that might help you decide whether or not you want your child to participate
in the study?
By signing below, you are giving permission for your child to participate in the research described above.
Please sign only if:
9 You understand the information about the research described in this consent form,
9 You have had all of your questions answered fully, and
9 You give permission for your child to participate.
You will be given a copy of this consent form to keep.
Name of Child: ______________________________________________
Parent/Guardian’s Signature: _________________________________ Date: _________
Interviewer’s Signature: ______________________________________ Date: _________
Recordings
We are using a special quality control system on this project. The system runs on the computer and will
record what your child and I say to each other during several different parts of the interview. Neither of
us will know when the computer is recording what we say. The recording will be reviewed by people at
RTI to monitor my work, and will be kept private. Your child may participate in the interview even if
you do not consent to the recordings. May we use this quality control system during the interview with
your child?
By signing below, you are agreeing we may use this quality control system.
Parent/Guardian’s Signature: _________________________________ Date: _________

Assent Form for Accompanied Adolescent
(Ages 13–17) Survey Participation

Assent Form for Accompanied
Adolescent (Ages 13–17) Survey Participation
Bureau of Primary Health Care Patient Surveys

About the Surveys
The Primary Health Care Patient Surveys are research studies being conducted by RTI
International. The surveys are sponsored by the Bureau of Primary Health Care within the Health
Resources and Services Administration (HRSA). They are about people who receive health care
at places like this health center. The surveys will try find out what kinds of health problems
people come to health centers with and how well the health centers are meeting the needs of the
people who use them. You are one of about 4,000 people that RTI has selected to participate.
Participation
(NAME OF PARENT/GUARDIAN) said it is okay for me to invite you to talk with me about
your health and the services that you receive at this health care center. If it is okay with you, I
would like to ask you some questions. Some of the questions may be personal, such as questions
about drug or alcohol use and your feelings. Most of the questions are about less sensitive things
like health care received and whether or not you have certain health conditions like asthma or
diabetes. Some people will get a shorter interview, while others will take a bit longer. The
interview may last about an hour.
Voluntary Participation
You may choose whether or not you would like to participate. If you choose not to participate it
will not affect any services you may receive at the health center or from any other programs. If
you do not want to answer some of the questions you are asked, that is okay. If you decide not to
finish the questions, that is okay too. It is possible that some questions may make you
uncomfortable or feel various emotions. If you need to take a break at any time, just let me know.
Benefits
There are not any direct benefits to you. However, you will be helping us learn more about the
health needs of people who use health centers like this one.
Compensation for Participation
If you participate, you will be provided with $25 cash or a gift of equal value to thank you for
your time.
Risks of Study Participation
There are two risks involved in study participation. One risk is that the questions we ask might
make you feel uncomfortable or upset. If you feel uncomfortable or upset during the interview,
you may ask the interviewer to take a break or to skip any of the questions. The other risk is that
someone might find out what you tell us during the interview. To avoid that, we will do the
interview in private where no one can hear your answers. We will also create a number and use it
instead of your name to identify your interview in the computer. This will prevent anyone from
finding out what your answers were.
Your Privacy
Anything you tell me is private. The privacy of your answers is very important, so let me say a
little more about it. I am going to enter your answers into this computer. As mentioned, your

answers will be linked to a number instead of your name so no one else will know how you
answered the questions. Everyone involved in this research has signed an agreement stating they
will protect the privacy of the information you provide. The information that you tell me will not
be shared with anyone at this health care center. Your parent/guardian will not see your answers,
and we will not discuss any of your answers with them.
Exceptions to Privacy Pledge
There is one important exception to this promise of privacy. If I learn during our talk that your
life or health, or another person’s life or health could be in danger, I am required to inform the
clinic staff or the proper authorities.
Questions
If you have any questions about these studies, you may call FIELD DIRECTOR 1 NAME at
(XXX)XXX-XXXX or FIELD DIRECTOR 2 NAME at (XXX)XXX-XXXX. If you have any
questions about your rights as a study participant, you may call RTI’s Office of Research
Protections toll-free at (1-866-214-2043).
Do you have any questions that might help you decide whether or not you want to participate in
the study?
By signing below, you are agreeing to participate. Please sign only if:
9 You understand the information about the research described in this consent form,
9 You have had all of your questions answered fully, and
9 You want to participate.
You will be given a copy of this consent form to keep.
Respondent’s Signature: ___________________________________________ Date:
_________
Interviewer’s Signature: ___________________________________________ Date:
_________

Recordings
We are using a special quality control system on this project. The system runs on the computer
and will record what we say to each other during several different parts of the interview. Neither
of us will know when the computer is recording what we say. The recording will be reviewed by
people at RTI to monitor my work, and will be kept private. You may participate in the interview
even if you do not consent to the recordings. May we use this quality control system during your
interview?
By signing below, you are agreeing we may use this quality control system.
Respondent’s Signature: ___________________________________________ Date:
_________

Screener

Patient Screening Form
Primary Health Care Patient Survey

FRONT END:
PROGRAMMER: WE WILL NEED TO DEVELOP THE FOLLOWING VARIABLES
FROM INORMATION GATHERED AT GRANTEE RECRUITMENT:
DEVELOP VARIABLE “Fac1”=NAME OF FACILITY [ALLOW 40]
DEVELOP VARIABLE “State” [ALLOW 2 CHARACTER STATE ABBREVIATION]
PROGRAMMER: DO NOT ALLOW DK OR REF RESPONSE FOR ANY OF THE
SCREENER QUESTIONS (S1b, S2a, S2b, S2c, S4a, S4b, S4c, S4d).

S1a.

IS THIS A PROXY INTERVIEW?
1=YES [USE TO DEVELOP PROPER FILLS] -- CONTINUE
2=NO – GOTO S3

S1_child
child.

What is your child’s first name? I just need a way of referring to your
[Allow 20]

S3. What is [your age] [your child’s age]?
PROBE FOR BEST ESTIMATE, IF NECESSARY
____ YEARS [ALLOW 0-109]
[IF NOT A PROXY INTERVIEW AND AGE ENTERED IS LE 12, PRESENT
ERROR MESSAGE: “Children 12 years old and younger should only be
interviewed through a proxy. Back up to S1a.”]
S_INT1.
The first few questions are for statistical purposes only, to help us analyze the results of
the study.
Do you consider {FILL: yourself/name} to be Hispanic or Latino(a)?
1=YES
2=NO

3=GUESS BY FI – YES
4=GUESS BY FI - NO
S_INT2
What race or races do you consider {FILL: yourself/name} to be? {FILL: Are you/Is
he/she}...
You may select all that apply.
EXPLAIN, IF NECESSARY: “We ask this for statistical purposes only, to help us
analyze the results of the study.”
CODE “NATIVE AMERICAN” AS “AMERICAN INDIAN”;
IF UNABLE TO COMPLETE SCREENING, ENTER YOUR BEST GUESS BASED
ON OBSERVATION
1=White
2=Black or African American
3=American Indian or Alaska Native
4=Native Hawaiian or Other Pacific Islander
5=Asian
6= OTHER
7=ANSWERS GUESSED BY FI – R or PROXY REF
S_INT3.
IF SELF-RESPONDENT: RECORD; IF NOT OBVIOUS, ASK: What is your gender?
IF PROXY-RESPONDENT, ASK: What is {FILL: name’s} gender?
[SHOW ONLY FOR RESPONDENTS GE 13 YEARS OLD, NON PROXY
INTERVIEWS:] IF R ANSWERS THAT THEYARE TRANSGENDER AND
WHICH KIND IS NOT OBVIOUS – PROBE IF THEY ALTERED GENDER
FROM MALE TO FEMALE OR FROM FEMALE TO MALE
IF UNABLE TO COMPLETE SCREENING, ENTER YOUR BEST GUESS BASED
ON OBSERVATION

EXPLAIN, IF NECESSARY: “We ask this for statistical purposes only, to help us
analyze the results of the study.”
[SHOW OPTIONS 5 AND 6 ONLY FOR RESPONDENTS GE 13 YEARS OLD, NONPROXY INTERVIEWS]
1=MALE
2=FEMALE
3=(PROXY IW) GUESS BY FI: MALE
4=(PROXY IW) GUESS BY FI: FEMALE
5= TRANSGENDER MALE TO FEMALE
6= TRANSGENDER FEMALE TO MALE

S1b.

Thank you for your interest in participating in this patient survey. I have a few
questions to determine whether or not [you are /name is] eligible.
[Have you] [Has your child] received services from a health care professional
such as a doctor, nurse, drug counselor, mental health counselor, or dentist at
[NAME OF HEALTH CARE CENTER SITE] in the last 12 months?
1=YES
2=NO --- GOTO END1

S2_Intro
S2a.

Do any of the following apply to you?

Have you worked as a farmworker in the past 24 months or have you or has
anyone in your family been supported by someone who worked as a farmworker
in the past 24 months?
1=YES
2=NO

S2b.

In the past 12 months, has there been a period in which you have been without
regular housing or homeless? To clarify, that is not living in your own house,
apartment, or room on a regular basis and not in a hospital or jail/prison. For
example, living in a shelter, on the street/campsite/car/etc. or in temporary or
transitional housing where services are provided.
1=YES

2=NO
S2c.

Are you currently living in a public housing unit? Do not count Section 8 housing
as public housing.
1=YES
2=NO

S4_Intro.

INTERVIEWER: PLEASE ANSWER THE FOLLOWING QUESTIONS

S4a.

HAS YOUR QUOTA BEEN MET FOR FARMWORKERS
1=YES
2=NO

S4b.

HAS YOUR QUOTA BEEN MET FOR HOMELESS
1=YES
2=NO

S4c.

HAS YOUR QUOTA BEEN MET FOR PUBLIC HOUSING
1=YES
2=NO

S4d.

HAS YOUR QUOTA BEEN MET FOR CHC
1=YES
2=NO

SELECTION:
IF S2a=1 AND S4a=2 THEN CREATE NEW VARIABLE FARM1=1, ELSE
FARM1=2
IF S2b=1 AND S4b=2 THEN CREATE NEW VARIABLE HOME1=1, ELSE
HOME1=2
IF S2c=1 AND S4c=2 THEN CREATE NEW VARIABLE PUB1=1, ELSE PUB1=2
IF S4d=2 AND S2a = 2 AND S2b = 2 AND S2c = 2 THEN CREATE NEW
VARIABLE CHC1=1, ELSE CHC1=2
IF FARM1=2 and HOME1 = 2 and PUB1 = 2 and CHC1=2 THE CREATE NEW
VARIABLE CALLED PTYPE AND SET PTYPE TO EQUAL 5. SKIP TO
END1.
S4e.
IF FARM1=1 AND HOME1=2 AND PUB1=2 AND CHC=2, THEN SET PTYPE = 2
AND FILL: “RESPONDENT INTERVIEW SELECTED AS
FARMWORKER – PLEASE UPDATE QUOTA AND CONTINUE WITH
INTERVIEW”

IF HOME1=1 AND FARM1=2 AND PUB1=2 AND CHC=2 THEN SET PTYPE = 3
AND FILL: “RESPONDENT INTERVIEW SELECTED AS HOMELESS –
PLEASE UPDATE QUOTA AND CONTINUE WITH INTERVIEW”
IF PUB1=1 AND HOME1=2 AND FARM1=2 AND CHC=2 THEN SET PTYPE = 1
AND FILL: “RESPONDENT INTERVIEW SELECTED AS PUBLIC
HOUSING – PLEASE UPDATE QUOTA AND CONTINUE WITH
INTERVIEW”
IF CHC1=1 AND S2b=2 AND S2c=2 AND S2a=2 THEN SET PTYPE = 4 AND
FILL: “RESPONDENT INTERVIEW SELECTED AS CHC – PLEASE
UPDATE QUOTA AND CONTINUE WITH INTERVIEW”
MULTIPLE SELECTION:
IF 2 OR MORE OF THE FOLLOWING: FARM1=1 AND/OR HOME1=1
AND/OR PUB1=1 THEN CONTINUE ELSE GOTO END1
SELECTION OF VARIABLES WHEN 2 OR MORE OF THE FOLLOWING
(FARM1, HOME1, PUB1) = 1. IF PUB1=1 THEN SET PTYPE =1 AND
FILL “RESPONDENT INTERVIEW HAS BEEN SELECTED AS [FILL:
PUBLIC HOUSING], ELSE IF FARM1=1 THEN SET PTYPE =2 AND
FILL “RESPONDENT INTERVIEW HAS BEEN SELECTED AS [FILL:
MIGRANT], ELSE IF HOME1=1 THEN SET PTYPE =3 AND FILL
“RESPONDENT INTERVIEW HAS BEEN SELECTED AS [FILL:
HOMELESS],
“PLEASE UPDATE QUOTA AND CONTINUE WITH INTERVIEW”
IF S3 = 13, 14, 15, 16, OR 17 CONTINUE
IF S3 = LE 12 = GOTO INTRO1, ELSE GO TO INTRO2
S5.

Is a parent or guardian with you?
1=YES
2=NO
IF S5=1 GOTO INTRO3, ELSE GO TO END2

END1

Thank you very much, but unfortunately you were not selected for interview.

END2

Thank you very much, but unfortunately we need to speak with your parent or
guardian to gain their permission for you to continue with the interview.