ATTACHMENT C-1: Screening Instrument
CDC Message Testing: Radiation Emergencies Infographics
(Online Survey)
Form
Approved
OMB No. 0920-0572
Exp. 02/28/2015
LEVEL 1
In which of the following categories does your age fall? (A.2.a)
01 under 18 years of age [THANK AND TERMINATE]
02 18-24 years of age
03 25-34 years of age
04 35-44 years of age
05 45-54 years of age
06 55-64 years of age
07 65-74 years of age
08 75 years of age or older
[RECRUIT A MIX]
Do you, or does any member of your household or immediate family work (B.1.b):
01 For a market research company
02 For an advertising agency or public relations firm
03 In the media (TV/radio/newspapers/magazines)
04 As a healthcare professional (doctor, nurse, pharmacist, dietician, etc.)
05 An employee for any of the following:
Employee of U.S. Department of Health and Human Services
Employee of state or local health department
Employee of Department of Homeland Security
Employee of state or local emergency management agency
Nuclear power plant employee, Radiation Safety Officer, health physicist or other radiation-related occupation
[IF YES TO ANY, THANK AND TERMINATE]
Public reporting burden of this collection of information is estimated to average 3 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 (0920-0572).
LEVEL 2
Gender (A.1.a)
01 Male
Female
[RECRUIT ABOUT A 50/50 MIX]
[FOR WOMEN] Have you been pregnant in the past year? (A.46.a)
01 YES -> SHOW PREGNANCY INFOGRAPHIC
02 NO -> DO NOT SHOW PREGNANCY INFOGRAPHIC
DEMOGRAPHICS
What is the highest level of education you have completed? (A.4.a)
01 Grade school
02 Less than high school graduate/some high school
03 High school graduate or completed GED
04 Some college or technical school
05 Received four-year college degree
06 Some post graduate studies
07 Received advanced degree
[RECRUIT A MIX]
|
Categories |
a. ____ No, not of Hispanic, Latino/a, or Spanish origin (SKIP TO QUESTION 8) |
b. ____ Yes, Mexican, Mexican American, Chicano/a |
c. ____ Yes, Puerto Rican |
d. ____ Yes, Cuban |
e. ____ Yes, Another Hispanic, Latino/a or Spanish origin |
a. ____ White |
b. ____ Black or African American |
c. ____ American Indian or Alaska Native |
d. ____ Asian Indian |
e. ____ Chinese |
f. ____ Filipino |
g. ____ Japanese |
h. ____ Korean |
i. ____ Vietnamese |
j. ____ Other Asian |
k. ____ Native Hawaiian |
l. ____ Guamanian or Chamorro |
m. ____ Samoan |
n. ____ Other Pacific Islander |
[RECRUIT A MIX]
[DOCUMENT ON GRID]
In what state, city, and zip code do you currently live? ENTER FIVE DIGIT ZIP CODE. (A.9.a)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | wernerk |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |