Attachment 2F: Telephone administered Screener
OMB
No.: 0925-0645
Expiration
Date: 12/31/2014
Collection
of this information is authorized by The Public Health Service Act,
Section 411 (42 USC 285a). 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
kept private under the Privacy Act. Names and other identifiers
will not appear in any report of the study. Information provided
will be combined for all study participants and reported as
summaries. You are being contacted by telephone and mail to
complete this instrument so that we can learn more about informed
consent and perspective taking.
Public
reporting burden for this collection of information is estimated to
average 10 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 (0925-0645). Do not
return the completed form to this address.
I’m calling in response to your message about the study advertised [in the newspaper/ on craigslist]. I’d like to ask you a few questions to determine whether you are eligible to participate in this research. First, let me give you a bit of information about the research, which involves perspective taking and pretesting a consent form. You will receive $50 for participating in the study, which will take approximately one hour. Participation is entirely voluntary and you may refuse to complete the research at any time, even after you’ve agreed to participate.
Are you still interested in taking part in the study? [No, say thank you and terminate; Yes, go on]
Participation will involve using a computer. Are you comfortable using a computer? [No, say thank you and terminate; Yes, go on]
Ok, now I have a more few questions:
Can you read a computer screen without difficulty (with your contacts or eyeglasses on, if applicable?) [No, say thank you and terminate; Yes, go on]
Do you use a screen reader, screen magnifier, or other assistive technology to use the computer? [Yes, say thank you and terminate; No, go on]
Do you have cataracts? [Yes, say thank you and terminate; No, go on]
Do you have any eye implants? [Yes, say thank you and terminate; No, go on]
Do you have Glaucoma? [Yes, say thank you and terminate; No, go on]
Are either of your pupils permanently dilated? [Yes, say thank you and terminate; No, go on]
Do you have a history of epilepsy, seizures, or a sensitivity to flashing lights? [Yes, say thank you and terminate; No, go on]
Do you wear trifocal contact lenses? [Yes, say thank you and terminate; No, go on]
Are you currently being treated for cancer? [Yes, say thank you and terminate; No, go on]
Have you ever been in a medical clinical trial? [Yes, say thank you and terminate; No, go on]
What is your age?
What is your sex?
Male
Female
What is your ethnicity? (Choose one)
Not Hispanic or Latino
Hispanic or Latino
What is your race? (Choose one or more)
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
What is your contact information?
Are you available for a 1 hour interview on [DATE/TIME] at {LOCATION]?
| File Type | application/msword |
| Author | Rebecca Anne Ferrer |
| Last Modified By | Vivian Horovitch-Kelley |
| File Modified | 2012-08-22 |
| File Created | 2012-07-17 |