Revised Screener Instrument

Attachment 2

Screener Instrument for Nurses, Counselors, Teachers, and Administrators

Form Approved

OMB No. 0920-0811

Exp. Date 05/29/2010

In-Depth Interview Screener

Project: Traumatic Brain Injury in Schools

Client: CDC

Date: September 2008

A total of 45 interviews will be conducted with four audiences (school nurses, school counselors, school teachers and school administrators).

NOTES FOR RECRUITERS

• Please note that all recruitment quotas should be filled for each of the four audiences. For example, “recruit a mix” means that there should be a mix within each audience (nurses, counselors, teachers, and administrators), not the entire study population.

• Please use the following language for termination of screening:

“Thank you very much for your time today. We are looking to recruit a variety of professionals from across the country to help with this study, and we have already recruited enough people with similar backgrounds. We are still in the process of recruitment, and if we need your help, we will call you back. Again, thank you for your interest. If you have questions about traumatic brain injury, please visit www.cdc.gov/ncipc or call 1-800-CDC-INFO.”

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).

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 school nurses, counselors, teachers, and administrators on behalf of the Centers for Disease Control and Prevention (CDC). I would like to ask you some questions to see if you qualify to participate in a brief telephone discussion about traumatic brain injury or TBI. These questions will only take a few moments to answer. Everyone who qualifies for and participates in these discussions will be paid $40. The discussion can be scheduled at a time convenient to you and will last up to 60 minutes. Do you have time now to answer a few questions to see if you qualify?

1. Which of the following best represents your job title?

( ) School Nurse Continue

( ) School Teacher Continue

( ) School Counselor Continue

( ) School Administrator Continue

( ) Other (contact AED if uncertain) Terminate

2. For NURSES: Which of the following best describes your qualifications?

( ) 2 year certified Continue

( ) 3 year certified Continue

( ) 4 year certified / Bachelor’s / Registered Nurse (RN) Continue

( ) Master’s Degree / Master’s Prep / Nurse Practitioner Continue

( ) Practical Nurse (LPN) Continue

( ) PhD / Doctorate Continue

( ) Other: Record Continue

Recruit at least three different categories and no more than 50% of any category.

For TEACHERS: Which of the following best describes your qualifications?

( ) Bachelor’s Degree Continue

( ) Master’s Degree Continue

( ) PhD / Doctorate Continue

( ) Other: Record Continue

Recruit at least two master’s.

For COUNSELORS: Which of the following best describes your qualifications?

( ) Master’s Degree Continue

( ) Doctorate Continue

( ) Other: Record Continue

Recruit at least two master’s and two PhD/Doctorate.

For ADMINISTRATORS: Which of the following best describes your qualifications?

( ) Superintendent Continue

( ) Principal Continue

( ) Vice-Principal Continue

( ) Other: Record Continue

Recruit no more than 50% of any category.

3. Record Gender

( ) Male Continue

( ) Female Continue

Recruit at least four males and four females.

4. What type of school do you work at?

( ) Nursery School / Pre-Kindergarten Only Terminate

( ) Elementary school (grades K-5) Continue

( ) Middle school (6-9) Continue

( ) High school (10-12) Continue

( ) Post secondary (college, technical school, etc) Terminate

( ) Mixture of school types Record: ________________ Continue*

( ) Other Record: _____________________ Terminate

Recruit a mix.

* Terminate if 50% of time is not elementary school, middle school, or high school.

5. Have you ever worked with a student or students with a traumatic brain injury? By traumatic brain injury or TBI, I mean a brain injury that is caused by a bump, blow or jolt to the head that disrupts the normal function of the brain. A TBI can also be caused by a penetrating head injury. A concussion is a form of mild TBI.

If more explanation is needed: A traumatic brain injury results from an external force. The leading causes of TBI are falls, motor vehicle-traffic crashes, struck by/against events, and assaults. Traumatic brain injuries do not include brain injuries caused by insufficient oxygen, poisoning, stroke or infection.

( ) Yes Continue

( ) No Continue

Recruit as it falls.

For NURSES: Recruit a minimum of five “yes.”

6. How many schools do you work at?

( ) One Continue

( ) Two or more: Record Actual number____________ Continue

Recruit at least three individuals who work at more than one school.

7. On average, how many hours do you spend at each school per week?

Record Actual number____________

8. How would you describe the setting of the school(s) you work in?

( ) Public Continue

( ) Private Continue

( ) Mix of public and private Continue

( ) Other: Record Response: ___________________ Continue

Recruit at least 50% public.

9. How would you describe the location of your workplace?

( ) Rural Continue

( ) Suburban Continue

( ) Urban Continue

Recruit at least 2 from each location.

9a. If urban:

Do you work in a large urban city center?

( ) Yes Continue

( ) No Continue

Recruit at least 1 from a large urban city center.

10. What state do you currently work in?

Northeast

( ) Connecticut

( ) Maine

( ) Massachusetts

( ) New Hampshire

( ) New Jersey

( ) New York

( ) Pennsylvania

( ) Rhode Island

( ) Vermont

Midwest

( ) Illinois

( ) Indiana

( ) Iowa

( ) Kansas

( ) Michigan

( ) Minnesota

( ) Missouri

( ) Nebraska

( ) North Dakota

( ) Ohio

( ) Wisconsin

( ) South Dakota

South

( ) Alabama

( ) Arkansas

( ) Delaware

( ) District of Columbia

( ) Florida

( ) Georgia

( ) Kentucky

( ) Louisiana

( ) Maryland

( ) Mississippi

( ) North Carolina

( ) Oklahoma

( ) South Carolina

( ) Tennessee

( ) Texas

( ) Virginia

( ) West Virginia

West

( ) Arizona

( ) Alaska

( ) California

( ) Colorado

( ) Hawaii

( ) Idaho

( ) New Mexico

( ) Oregon

( ) Montana

( ) Utah

( ) Nevada

( ) Washington

( ) Wyoming

Recruit no more than 50% from any region. Must recruit from all 4 regions.

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

( ) African American/Black Continue

( ) Caucasian/White Continue

( ) Hispanic Continue

( ) Asian Continue

( ) Native American Continue

( ) Other Continue

Recruit a mix.

12. How long have you worked as a school [nurse, counselor, teacher, administrator]?

( ) under 2 years Continue

( ) 2-5 years Continue

( ) over 5 years Continue

Recruit at least one from each category.

13. Finally, can you tell me what interested you in working in a school and what you like most about your work?

This question is intended to establish whether the respondent is reasonably articulate, fluent in English, and willing to converse. If respondent has a strong accent, difficulty speaking English, serious speech impediment or has trouble communicating (e.g., “shuts down”), thank and terminate.

Invitation

Thank you for answering my questions. You qualify for the study. At this point, I am going to read you a short description of the project, and I will need you to confirm that you want to participate.

About the Project

The Academy for Educational Development (AED) and the Centers for Disease Control and Prevention (CDC), invite you to be in a research study. The goal of the study is to explore what school nurses, counselors, teachers, and administrators think about traumatic brain injury or TBI. The study will help CDC communicate with school nurses, counselors, teachers, and administrators about preventing and recognizing TBI. Please feel free to ask questions as I explain the study.

We will be interviewing professionals about where and how they get health information. We will also ask for opinions about messages that CDC may use in TBI educational materials.

If you agree to participate, you will be interviewed by a trained researcher for no more than 60 minutes. The information will be used to write a report that will inform CDC’s campaign. Your interview will be audio recorded and researchers associated with the study may listen and take notes. The notes and recording will be used to write a report.

The information you give us will be kept private. Your name will not be used in the interview, nor will it appear in the report. All notes and recordings will be kept in a locked cabinet, and no one outside this project will have access to them. Recordings will be deleted after the study.

The interview poses no risks to you. If you begin to feel uncomfortable at any time, you can refuse to answer questions or stop the interview. No one is trying to sell you anything.

Your participation is voluntary. If you agree to participate, you will receive a check for $40.

If you have any questions about this project, please call Elyse Levine at (202) 884-8913. If you have questions about your rights as a participant in this project or think you have been harmed, please call 1-800-584-8814. Leave a message with your name and phone number, and someone will call you back as soon as possible.

Do you have any questions at this point?

Participant Verbal Consent

I will read you a list of statements about this research. After, I will ask you for your full name, and whether you agree to be interviewed. This information will be kept in a secure place. It will not be connected to your interview. The interviewer will never know your full identity.

I understand and agree that:

• The interview will cover traumatic brain injury prevention and recognition.

• I may refuse to participate or stop the interview at any time.

• My name and opinions will be kept confidential. Only my first name will be used in the interview, or I may choose to use a fake name.

• My interview will be audio taped and researchers may observe.

• The interview will only be used for research.

• No one will try to sell me anything.

• I will receive $40 for participating.

• I have asked any questions I have.

Please state your name: ____________________________________________

Do you, (Name), agree to participate in a 60-minute interview about traumatic brain injury?

[Circle response] Yes No [Record date] ___________________________

Thank you. I would like to tell you a little more about the telephone discussion. You can schedule a time to be called, at work or home, anytime between [date] and [times]. Your session will last up to 60 minutes. Before the call you will be sent some information to look at. You will need to read this information and have it with you during the call. You will receive $40 for participating.

We are counting on your participation, so please be sure to contact us as soon as possible if something comes up and you can't attend. (GIVE PHONE NUMBER).

Before we hang up, let me get the correct spelling of your name, your address, phone numbers, and email address so we can give you a reminder call, send you materials to look over, and send your $40 honorarium for participating.

NAME______________________________ ___ MR. ____MRS. ____ MISS ____ MS. ___DR.

Phone to call for interview ______________________ Alternate # ____________________

ADDRESS ____________________________________________

____________________________________________

____________________________________________

E-MAIL

Thanks, again, for your time!

8