Field Test Screening Instrument

ATTACHMENT 4

FIELD TEST SCREENING INSTRUMENT

Form Approved

OMB No. 0920-XXXX

Exp. Date __xx/xx/20xx________

Public reporting burden of this collection of information is estimated to average 2minutes 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0762)

HEALTH PROTECION Screener

S1.     Hello, this is (INTERVIEWER) and I'm calling for the U.S. Department of Health and Human Services about a research study.  I have just a few questions to see if you qualify for the study. 

[FOR CELL PHONE SAMPLE ONLY] If you are currently driving a car or doing any activity that requires your full attention, I need to call you back at a later time. [SET APPOINTMENT AND END CALL IMMEDIATELY IF RESPONDENT IS DRIVING OR DOING AN ACTIVITY.]

Are you age 18 or older [LANDLINE SAMPLE ONLY: and a member of this household]?

YES 1 (GO TO s3)

NO 2 (LANDLINE SAMPLE: GO TO s2; CELL PHONE SAMPLE, GO TO THANK 2)

ANSWERING MACHINE AM

RETRY AUTODIALER RT

NONWORKING, DISCONNECTED, CHANGED NW

GO TO RESULT GT

S2. May I please speak with a household member who is age 18 or over?

AVAILABLE 1 (GO TO S1)

NOT AVAILABLE 2 (GO TO RESULT, CALLBACK APPT.)

THERE ARE NONE 3 (GO TO THANK2)

S3. Is this phone number used for…

Home use, 1 (GO TO S4)

Home and business use, or 2 (GO TO S4)

Business use only? 3 (GO TO THANK1)

S4. The U.S. Department of Health and Human Services wants to learn about the ways people find information about health. We are talking to thousands of people across the country and want to make sure that participants include a mix of different types of people, for example, people of different ages. In what year were you born?

ENTER YEAR	XXXX	(GO TO RECRUIT1)
REF	-7	(GO TO THANK2)
DK	-8	(GO TO THANK2)

RECRUIT 1: ELDERLY (AGE=65-85)

IF S4<1924 GO TO THANK2.

IF S4>1991 GO TO THANK2.

IF S4 GE 1924 AND S5<1944, SET RECRUIT1=VALID.

GO TO S6.

S5.	What is the highest grade or level of school you completed? [DO NOT READ LIST. ACCEPT ONLY ONE RESPONSE.]

LESS THAN HIGH SCHOOL, SOME H.S. BUT NO DEGREE (GRADES 9-11)	1	[GO TO S6]
GRADE 12, HIGH SCHOOL DIPLOMA, OR GED	2	[GO TO S6]
TRADE/TECHNICAL/VOCATIONAL TRAINING BEYOND H.S.	3	[GO TO S6]
SOME COLLEGE BUT NO DEGREE,ASSOCIATE’S DEGREE (AA)	4	[GO TO S6]
COLLEGE GRADUATE/BACHELOR’S DEGREE (B.A., B.S.)	5	[GO TO S7]
SOME GRADUATE OR PROFESSIONAL SCHOOL/GRADUATE OR PROFESSIONAL DEGREE	6	[GO TO S7]
REFUSED	-7	[GO TO S6]
DON’T KNOW	-8	[GO TO S6]

S6.	Do you have a high school diploma or its equivalent, a GED?

YES	1	(GO TO S7)
NO	2	(GO TO RECRUIT 2)
REFUSED	-7	(GO TO S7)
DON’T KNOW	-8	(GO TO S7)

RECRUIT 2: LOW SES (HS DIPLOMA OR LESS)

(S5=1 OR 2) OR S6 = 2, SET RECRUIT2=VALID.

GO TO S7.

.

S7.	Are you of Spanish, Hispanic, or Latino origin?

YES	1
NO	2
REFUSED	-7
DON’T KNOW	-8

S8.	Would you describe your race as... [READ 1-5. CODE ALL THAT APPLY.]

White,	1	(GO TO S9)
Black or African-American,	2	(GO TO RECRUIT 3)
American Indian or Alaska Native,	3	(GO TO S9)
Asian, or	4	(GO TO S9)
Native Hawaiian or Other Pacific Islander?	5	(GO TO S9)
OTHER (SPECIFY)______________	91	(GO TO S9)
REFUSED	-7	(GO TO S9)
DON’T KNOW	-8	(GO TO S9)

RECRUIT 3: LOW SES (LESS THAN HS DIPLOMA), AFRICAN AMERICAN

IF RECRUIT 2=VALID AND S9 = 2, SET RECRUIT3=VALID.

GO TO S9.

S9.	What language or languages do you speak most at home? [CODE ALL THAT APPLY; SELECT FROM PRE-CODED RESPONSES]

ENGLISH	1	(GO TO RECRUIT BOX)
SPANISH	2	(GO TO S10)
CANTONESE [IF CHINESE, PROBE FOR CANTONESE]	3	(GO TO S10)
VIETNAMESE	4	(GO TO S10)
OTHER	5	(GO TO RECRUIT 4)
REFUSED	-7	(GO TO S10)
DON’T KNOW	-8	(GO TO S10)

S10.	Would you say you speak only [SPANISH/CANTONESE/VIETNAMESE], more [SPANISH/CANTONESE/VIETNAMESE] than English, both equally, more English than [SPANISH/CANTONESE/VIETNAMESE], or only [SPANISH/CANTONESE/VIETNAMESE] at home?... [READ 1-5. CODE ALL THAT APPLY.]

ONLY [SPANISH/CANTONESE/VIETNAMESE],	1	[(GO TO RECRUIT 4)
MORE [SPANISH/CANTONESE/VIETNAMESE] than English	2	(GO TO RECRUIT 4)
BOTH EQUALLY	3	(GO TO RECRUIT 4)
MORE ENGLISH THAN [SPANISH/ CANTONESE/VIETNAMESE]	4	(GO TO RECRUIT BOX)
ONLY ENGLISH	5	(GO TO RECRUIT BOX)
REFUSED	-7	(GO TO RECRUIT BOX)
DON’T KNOW	-8	(GO TO RECRUIT BOX)

RECRUIT 4: FOREIGN LANGUAGE RESPONDENTS (SPEAK ALL/MOSTLY/EQUALLY SPANISH, VIETNAMESE OR CANTONESE)

[WESTAT ONLY]

IF S9=2 AND S10<4, SET RECRUIT4_SPANISH=VALID.

GO TO RECRUIT BOX.

[DAVIS ONLY]

IF S9=3 AND S11<4, SET RECRUIT4_CANTONESE=VALID.

IF S9=4 AND S11<4, SET RECRUIT4_VIETNAMESE=VALID.

GO TO RECRUIT BOX.

RECRUIT BOX

IF RECRUIT1=VALID: RECRUIT 50 ELDERLY IN EACH OF THE 5 CITIES (250 TOTAL)

IF RECRUIT2=VALID: RECRUIT 50 LOW SES IN EACH OF THE 5 CITIES (250 TOTAL)

IF RECRUIT3=VALID: RECRUIT 25 LOW SES AFRICAN AMERICANS IN LA, CHICAGO, WASHINGTON, DC (150 TOTAL)

IF RECRUIT3_SPANISH=VALID: RECRUIT 20 SPANISH-LANGUAGE RESPONDENTS IN CITIES 1, 2, AND 3 (30 TOTAL)

IF RECRUIT4_CANTONESE=VALID: RECRUIT 25 CANTONESE-LANGUAGE RESPONDENTS IN CITY 1 AND 50 IN CITY 2 (75 TOTAL)

IF RECRUIT4_VIETNAMESE=VALID: RECRUIT 25 VIETNAMESE-LANGUAGE RESPONDENTS IN CITY 1 AND 50 IN CITY 2 (75 TOTAL)

ELSE

RECRUIT 5: RECRUIT 150 OTHERS IN EACH OF THE 5 CITIES (750 TOTAL)

ELSE GO TO THANK2.

RECRUIT. We would like to ask you a few more questions. May I have just your first name?

NAME ______________________________ ( )

THANK1. Thank you, but we are only interviewing in residences.

THANK2. These are all the questions I have at this time. Thank you very much for your time.

Population*	City 1	City 2	City 3			Nat’l Panel	Total
				City 4	City 5
	Telephone (landline and Cell)					Web
General Population	150	150	150	150	150	250	1000
Elderly (age 65+)**	50	50	50	50	50	25	275
Low SES –General	50	50	50	50	50	25	275
Low SES –AA	25	25	25	25	25	25	150
Hispanics (in-language)	20	20	20	–	–	15	75
Chinese (in-language)	25	50	–	–	–	–	75
Vietnamese (in-language)	25	50	–	–	–	–	75
Total	345	395	295	275	275	340	1925

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