Communities Putting Prevention to Work (CPPW) National Media Initiative -- Message Testing

Communities Putting Prevention to Work (CPPW)

National Media Initiative — Message Testing

Attachment 2 to the HMTS Expedited Review Form

Contents

Attachment 2: Eligibility Screener 2

Form Approved

OMB No. 0920-0572 Exp. Date 2/28/2015

Attachment 2: Eligibility Screener

Communities Putting Prevention to Work (CPPW)

National Media Initiative — Message Testing

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).

I. GREETING AND SCREENER

Hello, my name is _______________. My company is conducting telephone interviews on behalf of the US Centers for Disease Control and Prevention – sometimes known as the CDC. We are interviewing adults across the country about several issues. We are NOT seeking contributions and we are NOT selling anything.

1. May I speak with the adult who is most responsible for making decisions about health and wellness in the household? (Do not read response options.)

( ) 1 YES Continue [if the call is given to another person, start from the beginning]

( ) 2 NO, NOT INTERESTED Thank and terminate

( ) 3 NO, NOT A GOOD TIME Ask and record information below

“Could, I could set up another time for this call?”

DAY/DATE: ____________ TIME: _____________

( ) 9 REFUSED Thank and terminate

[If YES, continue.]

We are trying to speak with a wide variety of people about issues related to health and wellness in your community. Before we begin, I’d like to learn a little about you.

2. Are you 24 years of age or older?

( ) 1 YES Continue

( ) 2 NO Thank and terminate

3. What is the zip code at the address where you live?

Zip: _________________________________ [Record and verify using list.]

( ) 8 Don’t Know/Not Sure (DO NOT READ)

( ) 9 Refused (DO NOT READ) Thank and terminate

4. Is this a cellular telephone?

( ) 1 YES Continue

( ) 2 NO Continue

( ) 8 Don’t Know/Not Sure (DO NOT READ)

( ) 9 Refused (DO NOT READ) Thank and terminate

Interviewer Note: Telephone service over the internet counts as landline service (includes Vonage, Magic Jack and other home-based phone services).

Read only if necessary: “By cellular (or cell) telephone we mean a telephone that is mobile and usable outside of your neighborhood.”

[Refer to sampling frame]

5. Do you consider yourself to be …? [Read responses 1 & 2]

( ) 1 Hispanic or Latino

( ) 2 Not Hispanic or Latino

( ) 8 Don’t Know/Not Sure (DO NOT READ)

( ) 9 Refused (DO NOT READ) Thank and terminate

[Refer to sampling frame]

6. Do you consider yourself to be…? [Read responses 1-5 and allow respondent to select one or more]

( ) 1 White/Caucasian

( ) 2 Black or African-American

( ) 3 American Indian or Alaska Native

( ) 4 Native Hawaiian or Other Pacific Islander

( ) 5 Asian

( ) 8 Don’t Know/Not Sure (DO NOT READ)

( ) 9 Refused (DO NOT READ) Thank and terminate

[Refer to sampling frame]

Please use the following termination language if the participant is not eligible: “Thank you very much for your time. I don’t have any further questions for you today.”