Attachment 1
Pre-Screening Telephone Interview |
OMB#: ####-#### EXP.DATE: ##/##/#### |
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN |
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Public reporting burden for this collection of information is estimated to average 15 minutes for this questionnaire, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review 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 current, 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN:PRA (####-####). |
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If interviewer is calling participant: Hello, my name is (Interviewer Name) and I’m calling you regarding the iDATA studyon behalf of the National Institutes of Health and AARP.
1a. May I speak with (person’s name)?
YES 1
NO 2
PROBABLE BUSINESS 3
ANSWERING MACHINE AM
NONWORKING, DISCONNECTED, CHANGED NW
REFUSED -7
DON’T KNOW -8
If participant is calling interviewer: Hello, my name is (Interviewer Name). Thank you for calling the iDATA study, which is being conducted by the National Institutes of Health and AARP.
1b. With whom am I speaking?
[Participant provided name]
Are you at least 18 years old?
YES 1
NO 2
GO TO RESULT GT
REFUSED -7
DON’T KNOW -8
Interviewer: A short time ago, we sent you a letter about an important health research study called iDATA. I’d like to describe the iDATA study to you to find out if you are interested and available to participate. If so, and you are eligible to participate, you will receive $400 for completing the study.
This study will last for one year and each month you will be asked to do something. You will be asked to come to our clinic on XXXX Street in Pittsburgh three times during the year: at the start of the study, half-way through, and at the end of the study. At the clinic visits, we will conduct a variety of different health and fitness tests , take a small amount of blood, and collect a urine sample. Additionally, every month we will ask to do something at home, such as complete an online food or physical activity questionnaire or collect a 24-hour urine sample. If needed, help with transportation to and from the clinic will be provided. It’s very important that participants complete all or as many of the study activities as they can throughout the full year of participation.
The iDATA Study is authorized by the Public Service Health Act. There will be no consequences should you decide not to participate or answer any questions. All your answers and test results will be kept private under the Privacy Act.
Can I answer any questions you might have at this point about the study?
Do you think you would be interested in participating in the iDATA study?
YES 1
NO 2
REFUSED -7
DON’T KNOW -8
At this point I will need to record your answers to a set of study eligibility questions. Do I have your permission to continue?
YES 1
NO 2
Will you be available to participate in a yearlong study that will require you to visit the Pittsburgh clinic three times throughout the year?
YES 1
NO 2 (Ineligible)
REFUSED -7
DON’T KNOW -8
Interviewer: To determine your eligibility for the iDATA study, it is important that you answer the following questions. All of your answers are kept private under the Privacy Act.
What is the month and year of your birth?
|__|__| / |__|__|__|__| (use provided list to convert birthdate to age)
That means that you are |__|__| years old. Is that correct?
YES 1
NO 2 Ineligible
Can you read English well?
YES / OK / PRETTY WELL 1
NO / A LITTLE / NOT TOO WELL / SO-SO 2 Ineligible
Do you have a computer and easy access to high-speed internet?
YES 1
NO 2 Ineligible
REFUSED -7
DON’T KNOW -8
Are you able to complete online surveys and questionnaires that may take up to an hour to complete?
YES 1
NO 2 Ineligible
REFUSED -7
DON’T KNOW -8
(Only if not obvious) For the record, are you male or female?
MALE
FEMALE
Are you currently trying to lose weight by dieting, taking medication, or using a liquid diet?
YES 1 Ineligible
NO 2
What is your height? |__| feet |__|__| inches
What is your weight? |__|__|__|
[BMI to be calculated based on height and weight. Ineligible if BMI <18.5 or >40]
Has a doctor or other health professional ever told you that you have…
High blood sugar that requires daily insulin shots to control?
YES 1 Ineligible
NO 2
Congestive heart failure?
YES 1 Ineligible
NO 2
Kidney failure that requires dialysis?
YES 1 Ineligible
NO 2
Difficulty with fluid retention, that is, swelling that results in more than 5 pounds of weight gain?
YES 1 Ineligible
NO 2
Malabsorption or food absorption problems, for example Crohn’s disease?
YES 1 Ineligible
NO 2
Hemophilia?
YES 1 Ineligible
NO 2
Do you currently take beta-blockers for a heart condition?
YES 1 Ineligible
NO 2
Do you currently use supplemental oxygen, such as oxygen by mask or by nose?
YES 1 Ineligible
NO 2
Are you able and willing to stop taking medications containing acetaminophen, sulphonamides, or vitamin supplements for the two-day urine collection period?
YES 1
NO 2 Ineligible
By yourself and without using any special equipment, how much difficulty do you have walking for a quarter of a mile [that is about 2 or 3 blocks]?
No difficulty
Some difficulty
Much difficulty……………..Ineligible
Unable to do……………….Ineligible
Do not do this activity…….Go to 20b
Refused
Don't know
Missing
20b. Do you think you could walk for a quarter of a mile without using any special equipment if asked?
YES 1
NO 2 Ineligible
PABA is a type of Vitamin B and is used in sunscreen. Do you have a sensitivity to the nutritional supplement called PABA or have you ever developed a skin rash or experienced itching following the application of a sunscreen that may have contained PABA?
YES 1 Ineligible
NO 2
DON’T KNOW
/DON’T THINK SO 3
Is there any other reason that might prevent you from participating in the whole study?
[INCLUDE A LIST OF REASONS]
Interviewer: Thank you for answering these questions. At this time it looks like you are:
Eligible Interviewer: We will need your full name and address in order to ship you an iDATA study information packet.
Please confirm your first name: ______________________
Please confirm your last name: ______________________
What is your street address? ______________________
City? ______________________
State? ______________________
Zip Code? ______________________
Home/Work/Mobile Phone #s ______________________
Best times to call? ______________________
Email address? ______________________
Ineligible Interviewer: Thank you for taking the time to answer the eligibility questions and for your interest in the iDATA study.
January 18, 2011
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Ann Truelove |
| File Modified | 0000-00-00 |
| File Created | 2021-02-01 |