Form 1 Parents/Caregivers (who refused)

SSA Attachment 9

HEALTHY COMMUNITIES STUDY

HEALTHY COMMUNITIES STUDY

DATA COLLECTION PROTOCOL FOR PARENTS WHO REFUSE

TO PARTICIPATE IN THE STUDY

This document provides an overview of the data collection process for a random sample of parents/caregivers who refused to participate in the Healthy Communities Study.

At the end of the field data collection in each community, an attempt will be made to contact and interview parents who were invited but who opted not to take part in the study using the non-respondent interview script. Contact will be attempted with five "failed contact" and five "refusal" randomly-selected parents to administer a ten-minute survey. The number of non-responders per community was selected to provide sufficient data (pooled across all communities) to assess whether there are significant differences between responders and non-responders, and to make appropriate adjustments for such biases if they exist.

HEALTHY COMMUNITIES STUDY

NONRESPONDENT HOUSEHOLD DATA COLLECTION PROTOCOLSCRIPT

Public reporting burden of this collection of information is estimated at 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining 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 S. Sonia Arteaga, Ph.D., project officer at hcs@nhlbi.nih.gov

Hello, my name is __________ and I am calling from the Healthy Communities Study. A few weeks ago we [contacted you/attempted to contact you] to participate in our study. Since you were one of the families that did not take part in our study, we are calling you today to ask a few basic questions. The answers to these questions will let us check if the families who did not participate in our study are different to those families that did participate – this is important in understanding our study results. Your responses will be kept private under the Privacy Act and you and your family’s name will not be identified in any report.

This call should take about 5 to 10 minutes. We will not be calling you again with more questions or asking for any other commitment from you. Is now a good time for you?

[IF RESPONDENT WHO ANSWERS PHONE DOES NOT SPEAK ENGLISH OR SPANISH, TRY TO SPEAK WITH SOMEONE IN HOUSEHOLD WHO DOES SPEAK ENGLISH OR SPANISH.  IF THERE ARE NO ENGLISH/ SPANISH -SPEAKING HOUSEHOLD MEMBERS, RECORD THAT THERE IS A LANGUAGE BARRIER AND END CALL.] 

If yes, proceed

If no, Ok, I can call back. When would be a more convenient time for you? [RECORD CALLBACK DETAILS AND END CALL]

These first set of questions are to find out if your family would have been eligible to take part in our study.

1. We are working in [Name of community]. We have on file that your current address is [address from InfoUSA database]. Is that your current address?

If yes, Great! (proceed to Q.2)

If no, Would you please give me your current address so I can see if it is within the community we are looking at?

If person does not want to disclose address: If you’d prefer to provide me with the closest intersection to your house (for example, 1^st street and Pennsylvania Avenue), I can use that to see if it falls into our community boundaries.

If address is in community: Thank you! Your address is within the community. (proceed to Q.2)

If address is NOT in community: I apologize – it appears that your address is not within the community we are studying. Thank you for taking the time to speak with me today. Have a great day! [END CALL]

2. Do you have any children between the ages of 3 and 15 years old living in your household?

If yes, Ok. (proceed to Q.3)

If no, Thank you for taking the time to speak with me today. Have a great day! [END CALL]

3. Has your family lived in this community for the past 1 year?

If yes, Great. (proceed to Q.4)

If no, Thank you for taking the time to speak with me today. Have a great day! [END CALL]

4. Do you and your family plan to stay in this community for the next 12 months?

If yes, Ok. (proceed to Q.5)

If no, Thank you for taking the time to speak with me today. Have a great day! [END CALL]

5. Next I need to know the age and gender of each child aged 3 to 15 years old who lives in your household. Please give me a first name, or the initials, for each child along with their age in years and gender. RECORD NAME, AGE, GENDER OF EACH CHILD

6. For each child, I need to confirm that the child lives at home and is able to walk. [REPEAT LIST OF CHILDREN PROVIDED IN Q. 5 AND RECORD IF CHILD LIVES AT HOME AND IS AMBULATORY]

These next set of questions are to collect some basic demographic information

7. Do you consider yourself Hispanic/Latin(o/a)?

YES 1

NO (SKIP TO Q8) 2

REFUSED (SKIP TO Q8) 97

DON’T KNOW (SKIP TO Q8) 98

If yes,

Which of the following represent your Hispanic origin or ancestry? [READ ANSWERS AND CODE ALL THAT APPLY]

PUERTO RICAN 1

DOMINICAN (REPUBLIC) 2

MEXICAN/MEXICAN AMERICAN 3

CUBAN/CUBAN AMERICAN 4

CENTRAL/SOUTH AMERICAN 5

OTHER LATIN AMERICAN 6

OTHER HISPANIC OR LATIN(O/A) 7

REFUSED 97

DON’T KNOW 98

8. (In addition to being Hispanic, what/What) race do you consider yourself to be? [SELECT ONE OR MORE]

WHITE 1

BLACK/ AFRICAN AMERICAN 2

AMERICAN INDIAN OR ALASKA NATIVE 3

NATIVE HAWAIIAN OR PACIFIC ISLANDER 4

ASIAN 5

REFUSED 97

DON’T KNOW 98

If response includes Native Hawaiian or Pacific Islander,

Which Native Hawaiian and/or Pacific Islander group? [SELECT ONE OR MORE]

NATIVE HAWAIIAN 1

GUAMANIAN 2

SAMOAN 3

OTHER PACIFIC ISLANDER (SPECIFY) 4

REFUSED 97

DON’T KNOW 98

SPECIFY:

If response includes Asian,

Which Asian group? [SELECT ONE OR MORE]

ASIAN INDIAN 1

CHINESE 2

FILIPINO 3

JAPANESE 4

KOREAN 5

VIETNAMESE 6

OTHER ASIAN (SPECIFY) 7

REFUSED 97

DON’T KNOW 98

SPECIFY:

9. Where were you born?

US STATE (SPECIFY) (SKIP TO Q10) 1

US TERRITORY OR FOREIGN COUNTRY(SPECIFY) 2

REFUSED (SKIP TO Q10) 97

DON’T KNOW (SKIP TO Q10) 98

SPECIFY:________________________________________

	What year did you come to live in the United States? YEAR REFUSED 9997 DON’T KNOW 9998 What is the highest grade or year of school you have completed or the highest degree you have received?
	NEVER ATTENDED/KINDERGARTEN ONLY 1 1ST GRADE 2 2ND GRADE 3 3RD GRADE 4 4TH GRADE 5 5TH GRADE 6 6TH GRADE 7 7TH GRADE 8 8TH GRADE 9 9TH GRADE 10 10TH GRADE 11 11TH GRADE 12 12TH GRADE 13 12TH GRADE, NO DIPLOMA 14 HIGH SCHOOL GRADUATE 15 GED OR EQUIVALENT 16 SOME COLLEGE, NO DEGREE 17 ASSOCIATE DEGREE: OCCUPATIONAL, TECHNICAL, OR VOCATIONAL PROGRAM 18 ASSOCIATE DEGREE: ACADEMIC PROGRAM 19 BACHELOR’S DEGREE (BA, AB, BS, BBA) 20 MASTER’S DEGREE (MA, MS, MENG, MED, MBA) 21 PROFESSIONAL SCHOOL DEGREE (MD, DDS, DVM, JD) 22 DOCTORAL DEGREE (PHD, EDD) 23 REFUSED 97 DON’T KNOW 98
	We would like to know about what you do – are you working full-time for pay now, working part-time for pay, looking for work, retired, keeping house, a student, or what? CODE ALL THAT APPLY WORKING FULL-TIME FOR PAY NOW 1 WORKING PART-TIME FOR PAY NOW 2 ONLY TEMPORARILY LAID OFF, on SICK LEAVE OR MATERNITY LEAVE 3 LOOKING FOR WORK, UNEMPLOYED 4 RETIRED 5 DISABLED, PERMANENTLY OR TEMPORARILY 6 KEEPING HOUSE 7 STUDENT 8 OTHER (SPECIFY) 9 REFUSED 97 DON’T KNOW 98
SPECIFY:
The next question is about your total family income in (LAST CALENDAR YEAR IN 4-DIGIT FORMAT) before taxes. This answer will be kept private under the Privacy Act like all the other information you provide. When answering this question, please remember that by “combined family income” I mean your income plus the income of all family members and partners living in the household. Please include income from jobs, government assistance, social security, disability, unemployment insurance, investments, and any other income that your family has.
	What is your best estimate of the total income of all family members from all sources, before taxes were taken out, in (LAST CALENDAR YEAR IN 4-DIGIT FORMAT)?
	INCOME $ , , REFUSED 9999997 DON’T KNOW 9999998

That completes our survey!

Thank you so much for taking the time to answer our questions. If you have any questions or concerns please call [phone number]. Have a wonderful day!