Home Appliance Owner: Traid Screener

Form Approved

OMB No. 0920-XXXX

Expiration Date XX/XX/20XX

ATTACHMENT 6:

TRIAD SCREENER FORM

(note: both homeowners and generator owners will use the same form)

Public reporting burden of this collection of information is estimated to average 10 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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Introduction

Hello, my name is _______________ and I’m from (name of company). We are calling on behalf of RTI International, a non-profit research organization, and the Centers for Disease Control and Prevention. We are not selling or promoting any product. We are calling about research that is being conducted on household safety.

The purpose of this research is to review information and materials on household safety that being developed. To see if you are eligible to participate in this discussion, I need to ask you some questions. If you are eligible and choose to participate, all of your comments will be kept private. To help reimburse you for any personal expenses, you will be provided $75.

The questions to see if you are eligible will only take a few minutes.

1. First, does any member of your household or immediate family work for or receive any compensation from:

A market research company _____

An advertising agency or public relations firm _____

The media (TV/radio/newspapers/magazines) _____

The Centers for Disease Control and Prevention (CDC) _____

A company that manufactures portable generators_____

[IF “YES” TO ANY  GET SPECIFICS, CONTINUE SCREENING, AND HOLD]

Furnace Homeowner Triads (Chicago)

2. Do you presently live in a single family home, which you or your spouse or partner own?

Yes		 CONTINUE
No		TERMINATE

3. In your home, what is the primary source of heating? [list the following types of heating systems]

Gas furnace		 CONTINUE
Oil furnace		 CONTINUE
Electric furnace or radiators		 TERMINATE
Fire or Wood Stove		 TERMINATE
Portable Space Heaters		 TERMINATE
Coal Heating System		 TERMINATE

4. In which postal zip code in the Chicago area is your home located? _______________________

[NO MORE THAN TWO HOMEOWNERS FROM THE SAME ZIP CODE]

5. What is your current age?

Yes	Between 25-45	 PLACE IN GROUP A OR B
No	≥ 60	 PLACE IN GROUP C OR D

Generator Triads (North Carolina)

2. Do you currently own a portable gasoline-powered generator?

Yes		 CONTINUE
No		TERMINATE

3. In which County of North Carolina do you live [list each option]?

Coastal Counties [Insert list of counties]		 PLACE IN GROUP A OR B
All other Counties		 PLACE IN GROUP C OR D

Triad Invitation:

Thank you for answering all of my questions. As I mentioned earlier, we are conducting a study on behalf of the CDC to review [home safety/generator safety] information that is being developed. In order to hear people’s opinions first-hand, we are conducting informal, small group discussions to be held on [DATES AND TIMES TBD]. The discussion will last about 2 hours and will be both interesting and informative. No one will attempt to sell you anything and no one will call you later as a result of your participation. To reimburse you for any personal expenses, you will receive $75 at the time of the session. This is an important research effort and we hope that you will be part of it. We can only invite a few individuals to take part, and if it’s okay, we would like to audio tape the discussion. Can we schedule your attendance?

Closing for Ineligible Participants:

I’m sorry. You are not eligible to be in this study. There are many possible reasons why people are not eligible for the study. These reasons were decided earlier by the researchers. We value your interest in this research study. Thank you for being willing to help us.

Participant Information

Triad:

NAME: ________________________________________________________

ADDRESS: _________________________________________________

CITY: _________________________________________________

ZIP CODE: _________________________________________________

EMAIL _______________________________________________________

What is the best time to reach you? What is the best telephone number to reach you at that time?

BEST TIME TO BE REACHED: ________________________________________

BEST PHONE NUMBER: ______________

Is there another time and number we can try if we miss you?

ALTERNATE PHONE NUMBER:

Your participation in this study is very important. If for some reason you will not be able to attend, please let us know right away. You can call us anytime at [insert phone number], and if we are not here, please leave a message.

Interviewer: ____________________

Supervisor Confirm: ____________________