Form 2 Screener Questionnaire

Attachment 5: Food Reporting Comparison Study Telephone Participation Screener/Confirmation Script

ID: | | | | | | | | | | |

OMB #: 0925-0605

Expiry Date: 10/31/2011

STATEMENT OF CONFIDENTIALITY

Collection of this information is authorized by The Public Health Service Act, Section 412 (42 USC 285 a-1). Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be held in professional confidence. Names and other identifiers will be separated from information provided and will not appear in any report of the study. Information provided will be combined for all study participants and report as statistical summaries.

NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN

Public reporting burden for this collection of information is estimated to average 5 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0605).

INTRODUCTION: Hello, may I speak with [RESPONDENT NAME]?

[IF NOT AVAILABLE, ASK]: When would be a good time to reach [RESPONDENT]? RECORD BEST DAY AND TIME ON CALL RECORD.

IF SOMEONE OTHER THAN RESPONDENT ASKS REASON FOR CALL: My name is [INTERVIEWER NAME]. I'm calling on behalf of the National Cancer Institute and your health center, about a research study that _____ expressed interest in.

IF RESPONDENT IS AVAILABLE: Hello, my name is [INTERVIEWER NAME]. I'm calling on behalf of the National Cancer Institute and your health center. Recently, you visited the website for the ASA24 Food Reporting Comparison Study and agreed to take part in this study. I would like to confirm that you would like to participate in this project. Your answers will be kept private under the Privacy Act and used only in combination with answers of all other respondents.

[IF NEEDED]: The ASA24 Food Reporting Study is being conducted jointly by your health center and the National Cancer Institute. Your health center invited you to join this study and you visited the ASA24 Food Reporting Comparison Study website. Your participation will allow us to test methods for collecting food intake information.

DOB What is your date of birth?

______ / _______ / _________

MM / DD / YY

IF BORN AFTER 1989 OR BEFORE 1939: OK, I see that you are not in the age group we need for this study, which is for those between 20 and 70 years of age. Sorry. I do thank you for your interest in the study. END.

INTERNET It is likely that you will be asked to log-in to a secure server and provide information using the internet. Do you have access to high-speed internet?

a. YES 01

b. NO 02 [THANK AND END]

ENGWELL How well do you read English? Would you say …

1. Some but not too well 01 [THANK AND END]

2. Well 02

3. Very well 03

GENDER If not obvious, ask: For the record, are you male or female?

a. Male 01

b. Female 02

ASK NEXT PREGNANT QUESTION TO FEMALES ONLY:

PREGNANT Are you currently pregnant?

a. YES 01 [THANK AND END]

b. NO 02

c. DK 03

WTLOSS Are you currently on a total liquid diet, or prepackaged diet plan such as Ultra SlimFast, Sweet Success, OptiFast, Jenny Craig, or NutriSystem?

a. YES 01

What is the name of this diet?_________________________[THANK AND END]

b. NO 02

NOTE: ALL OF THE FOLLOWING DIETS ARE ALSO INCLUDED:
PREPACKAGED MEALS: Medifast, BistroMD, Freshology Weight Loss, eDiets, Diet to Go, LIQUID DIETS: DynaTrim, FastForward Weight Loss Program Drink, New Lifestyle Liquid Diet

SURGERY Have you had any type of bariatric surgery for weight loss, such as gastric staples, or bands?

a. YES 01 [THANK AND END]

b. NO 02

PHONENUM For this study, it is very important that we are able to reach you by phone. What is the best phone number at which to reach you during the day or during the evening?

Daytime? _____________________________________

Evening? _____________________________________

EMVER The email address I have for you is (READ EMAIL ADDRESS). Is that correct? Correct if needed.

I have a few more questions for you today.

RACEETH1 Do you consider yourself to be Hispanic or Latino?

a. YES 01

b. NO 02

RACEETH2 For this next question, you may choose as many answers as apply. Do you consider yourself to be … (Mark all that apply)

a. American Indian or Alaska Native Yes No

b. Asian Yes No

c. Black or African-American Yes No

d. Native Hawaiian or Other Pacific Islander Yes No

e. White Yes No

HLTH In general, how would you describe your health? When answering this question, think about how you feel generally. Would you say excellent, very good, fair, or poor?

a. Excellent 01

b. Very good 02

c. Good 03

d. Fair 04

e. Poor 05

HGHT1 What is your current height without shoes on?

__________Feet and ___________inches

WGHT What is your current weight without shoes on?

__________ pounds

Just to confirm I entered this correctly, you said your height was _ feet and __ inches and that your weight is ___ pounds.

Is that correct?

BACK UP AND CORRECT IF NEEDED. WHEN CONFIRMED, CLICK NEXT TO CONTINUE.

QUESTION Do you have any questions about what you’ll be doing in the study?

(Use FAQs to respond to questions).

If you have no (further) questions, I would like to remind you that when you are to complete the survey on the computer, you will receive automated telephone messages letting you know that you have an e-mail message. The email will contain a link to the FORCS website and the survey. Please complete this survey on the same day that you receive the e-mail.

We will be mailing you a welcome letter with a check for $5, in an envelope with the FORCS logo. After you complete the first survey, we will send you $15. After you complete the second survey and a brief survey about yourself and your experience with the study, we will send you another check for $30.

AGREE: Do you agree to take part in FORCS?

a. YES 01

b. NO 02 [THANK AND END]

ADDRS: I would also like to collect your mailing address so that we can mail project related materials and $5 as a token of appreciation for participating in this study. You will also be receiving an additional $45.00 as you continue to take part in the study.

Record Address: _____________________________________________________

___________________________________________________________________

END Thank you for taking the time to talk with me today. We will be contacting you again soon.

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