Form 7 Screener Questionnaire for FEAST

Attachment 8: Screening Script – FEAST

NCI Food and Eating Assessment Study (FEAST)

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). Do not return the completed form to this address.

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 from Westat, a research firm located in Rockville, Maryland.

IF RESPONDENT IS AVAILABLE:

Hello, my name is [INTERVIEWER NAME]. I'm calling from Westat, a research firm located in Rockville, Maryland. I am calling to ask you to take part in a study to help us learn about how people think about food. The study will only take about 3 hours of your time over a two day period. If you choose to participate, we will ask you to come to our research facility in Rockville, Maryland to eat breakfast, lunch, and dinner on one day. Each meal will take approximately 45 minutes. The next day, we will ask you to attend a 45 minute visit to the same research facility to answer questions about your diet and health. You will receive $120 for your time. It is very important that you attend both days of the study. Being part of this study does not involve any risk to your health.

This research is authorized by the Public Health Service Act, and of course, your participation is entirely voluntary. Be assured there will be no consequences if you decide not to participate, either to the study as a whole or to any particular questions. Also, all of your answers will be kept confidential, and the results of the study will be reported only as grouped data with no individual data reported.

AGREE I would like to ask if you would like to participate in this project.

a. YES 01

b. NO 02 [THANK AND END]

DOB I’d like to confirm your date of birth ?  [READ FROM CALL RECORD] __/__/____ [MM/DD/YYYY]

IF younger than 20, thank and end.

ATTEND In order to participate, you will need to come to our research facility on two consecutive days. Are you able to come to Westat, located in Rockville, for breakfast, lunch, and dinner on one day, and then return the very next day for an interview session?

a. YES 01

b. NO 02 [THANK AND END]

INTERNET Do you have access to high-speed internet at your house?

a. YES 01

b. NO 02 [THANK AND END]

ENGWELL With regard to the English language, how well do you…?

a. understand it when it is spoken to you?

1. Some but not too well 01

2. Well 02

3. Very well 03

IF RESPONDENT HAS TROUBLE WITH THIS QUESTION: We are interested in your own opinion of how well you understand English when it is spoken to you.  Would you say you

a. understand spoken English?

1. Some but not too well 01

2. Well 02

3. Very well 03

b. how well do you speak English?

1. Some but not too well 01

2. Well 02

3. Very well 03

c. how well do you read English?

1. Some but not too well 01

2. Well 02

3. Very well 03

[IF ANY ANSWER TO ENGWELL=01, THANK AND END]

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

DPREF Do you have dietary preferences that cause you to be unable to eat the majority of foods offered to you?

a. YES 01 [THANK AND END]

b. NO 02

ALLERGY Are you allergic to any foods?

a. YES 01 [THANK AND END]

b. NO 02

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

a. YES 01 [THANK AND END]

b. NO 02

OTHER LIQUID DIETS INCLUDE DynaTrim, New Lifestyle Liquid Diet, Fast Forward Weight Loss Program Drink

OTHER PREPACKAGED DIETS INCLUDE: Medifast, BistroMD, Freshology Weight Loss, eDiets, Diet to Go

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

NUTREDUC Have you had any formal training or education in the field of nutrition, such as an associate, bachelor, or graduate-level degree in dietetics, nutrition, food science, or home economics?

a. YES…………………………….….. 01 [THANK AND END]

b. NO 02

PHONENUM For this study, it is very important that we are able to reach you. What is the best phone number at which to reach you in the…

Daytime? _____________________________________

Evening? _____________________________________

ADDRESS I would also like to confirm your mailing address so that we can mail project related materials. [READ FROM CALL RECORD]

Record Address: _____________________________________________________

___________________________________________________________________

RACEETH1 Do you consider yourself to be...

Hispanic or Latino? 01

Not Hispanic or Latino? 02

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

American Indian or Alaska Native Yes No

Asian Yes No

Black or African-American Yes No

Native Hawaiian or Other Pacific Islander Yes No

White Yes No

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

(Use FAQs to respond to questions).

END Thank you for taking the time to talk with me today. We will be contacting you soon to schedule your visits to our research facility.