Non-Parcipating Household (Screened)

Form Approved

OMB No. 0990-

Exp. Date XX/XX/XX13

Attitudes toward Electronic Health Information Exchange and Associated Privacy and Security Aspects

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-xxxx. The time required to complete the screener part of information collection is estimated to average (2 minutes) per response, including the time to review the introduction and determine a respondent’s eligibility. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Attitudes Toward Health Information Exchange Study Intro and Screening Script

A. Introduction

[IF CALL BACK: Hello, may I speak to ____________?]

This is __________ calling on behalf of the Department of Health and Human Services. We are conducting an important research study to learn more about what people think about electronic health information exchange, its related privacy and security aspects, and the ways that it may affect how you manage your health information. This survey will take approximately 18 minutes. I would like to speak to a member of the household who is age 18 or older.

I also want to let you know that this call may be monitored or recorded for quality purposes.

1 CONTINUE

[INTERVIEWER, READ IF NECESSARY: If you have any questions about the study, you can call Dawn Thomas-Banks toll-free at 1-800-334-8571 extension 26557. Ms. Thomas-Banks is a Survey Manager with RTI International, a not-for-profit research organization coordinating this research. If you have any questions about your rights as a study participant, you can call RTI's Office of Research Protection toll-free at 1-866-214-2043 or contact Mr. Steven Posnack of the Office of the National Coordinator for Health Information Technology at 202-690-7151.]

B. Eligibility

S1. Are you 18 years of age or older?

[TI: IF NO, ASK TO SPEAK TO SOMEONE OVER 18.]

1 YES {go to S2}

2 NO {go to Section C/Terminate}

-1 DK {go to Section C/Terminate}

-2 RF {go to Section C/Terminate}

S2. Is this {fill: phone number}?

1 YES {go to S2b}

2 NO {go to S2a}

-1   DK (go to S2a)

-2   RF {go to Section C/Terminate}

S2a. I seem to have dialed the wrong number. Thank you very much for your assistance.

[TI: REDIAL NUMBER TO CONFIRM INCORRECT]

S2b. In case we get disconnected or I need to call you back, can you please give me your first name? (ONLY IF NEEDED: Your initials will be fine.) _________________________________________

S3. I need to ask you a few questions in order to determine your eligibility for this study.

Is this a cell phone?

1 YES {go to S3a}

2 NO {go to S4}

-1   DK (go to Section C/Terminate)

-2   RF {go to Section C/Terminate}

(cell phone path = S3 – S3d) (landline path = S4 – S7)

S3a. Are you driving a vehicle at this moment?

1 YES {go to S3b}

2 NO {go to S3c}

S3b. When would be a better time to call you?

[If respondent indicates that they are willing to talk now: “I’m sorry, but for your safety we’re not able to do the interview while you’re driving. When would be a better time to call you?”]

1 SET CALLBACK USING THIS CELL PHONE NUMBER

2 R WANTS TO BE CALLED AT A DIFFERENT PHONE NUMBER (THIS WILL ADD A NEW ROSTER LINE)

{go to section C/Terminate}

S3c. Including this one, how many working cell phones do you have?

[RECORD NUMBER OF CELL PHONES] {go to S3d}

[RANGE 1-9]

-1   DK (go to S3d)

-2   RF {go to S3d }

S3d. Now excluding cell phones, how many telephone numbers do you have in your household that are used for talking rather than only for machines like faxes and computers?

[RECORD NUMBER OF OTHER PHONE NUMBERS] {go to NUM_ADULTS}

[RANGE 0-5]

-1   DK

-2   RF

{end of cell phone path, beginning landline path}

S4. Is this a private residence?

1 YES {go to S5}

2 NO {go to S4a}

-1   DK (go to S4a)

-2   RF {go to S4a }

S4a. Thank you very much, but we are only interviewing people in private residences.

[TERMINATE INTERVIEW]

S5. Including the number I just dialed, how many different telephone numbers do you have in your household that are used for talking, excluding cell phones and telephone lines that are used only for machines like faxes and computers?

[RECORD NUMBER OF TELEPHONE NUMBERS]

[RANGE 1-5]

-1   DK

-2   RF

S6. How many working cell phones do you have?

[INTERVIEWER: BY WORKING CELL PHONE WE MEAN AN ACTIVE CELL PHONE]

[RECORD NUMBER OF CELL PHONES] {if 0, go to S7; else go to NUM_ADULTS}

[RANGE 0 - 9]

-1   DK

-2   RF

S7. Does anyone else in your household have a working cell phone?

1 YES {go to NUM_ADULTS}

2 NO {go to NUM_ADULTS}

-1 DK {go to NUM_ADULTS}

-2 RF {go to NUM_ADULTS}

NUM_ADULTS

We need to randomly select one adult who lives in your household to be interviewed. Including yourself, how many adults age 18 or older currently live in your household?

[RECORD NUMBER OF ADULTS] {if NUM_ADULTS =0, go to S8; if NUM_ADULTS =1, go to S9; if NUM_ADULTS ≥ 2, go to S10}

[RANGE 1 – 10]

-1 DK

-2 RF

S8. We are only interviewing adults age 18 or older, so those are all the questions I have for you. Thank you for your time.

[TERMINATE INTERVIEW – CODE AS INELIGIBLE]

S9. Are you the adult?

1 YES {go to S11}

2 NO {go to S10a}

S10. I need to speak with the adult living in your household who had a birthday most recently. Who would that be?

1 Person on phone is targeted Respondent – {go to S11}

2  Other in HH is targeted R go to S12}

-1  DK-Person on phone isn’t sure who in house this would be {go to S10a}

-2 RF {go to Section C/Terminate}

S10a. May I speak to another adult in the household?

1 YES {go to section D/Informed Consent}

2 NO- adult is not available during this call {go to Section C/Terminate}

-1 DK {go to Section C/Terminate}

-2 RF {go to Section C/Terminate}

S11. Great. Then you are the person I need to speak with.

{go to Informed Consent screen/Section D}

S12.  What is their first name? (ONLY IF NEEDED: Their initials will be fine.)  _____________________________

S12a.  May I please speak with [fill NAME from S12]?

1  Respondent comes to phone- {go to S13}

5  Respondent unavailable—Schedule Callback {go to Section C/Terminate}

-2  RF-Refusing to get selected R on phone—{go to Section C/Terminate}

S13. (IF SELECTED R COMES TO PHONE: Hello, this is __________ calling on behalf of the Department of Health and Human Services. We are conducting an important research study. {go to Informed Consent Screen/Section D}

C. Terminate

Thank you for your time.

RECORD REASON FOR TERMINATION

1 RESPONDENT WAS NOT 18 YEARS OF AGE OR OLDER

2 INCORRECT PHONE NUMBER

3 ELIGIBLE RESPONDENT COULD NOT BE IDENTIFIED

4 REFUSAL

5 OTHER REASON

D. Informed Consent

CONSENT 1. The purpose of this study is to understand more about what adults think about electronic health information exchange, its related privacy and security aspects, and the ways that it may affect how you manage your health information. Your help is voluntary, but important. If we come to a question you don’t want to answer, we will skip over it. You can end the interview at any time. The information you provide will be kept strictly confidential. The interview only takes about 12 minutes. I also want to let you know that this call may be monitored or recorded for quality purposes. Do you have any questions about the study?

1 CONTINUE

(Cell phone sample only: Before we begin, I want to make sure this is a good time for you to talk and that you are in a private place to use your cell phone. If at any point you would prefer to go to another room or another phone where I could call you back, just let me know.)

1 CONTINUE

CONSENT 2. If now is a good time let’s begin …

1 START NOW

2 SCHEDULE CALLBACK

3 R WANTS TO BE CALLED AT A DIFFERENT PHONE NUMBER (THIS WILL ADD A NEW ROSTER LINE)

-2 REFUSED

E. Call-in

Thank you for calling about this important research study being conducted for the United States Department of Health and Human Services. This study is an effort to learn more about what people think about electronic health information exchange, its related privacy and security aspects, and the ways that it may affect how you manage your health information.. I would like to speak to a member of the household age 18 or older to see who in your household is eligible for this study.

I also want to let you know that this call may be monitored or recorded for quality purposes.

(Go to S1)

F. Refusal

Hello, this is _______ calling on behalf of the United States Department of Health and Human Services. My supervisor asked me to follow-up with you concerning a call you received from one of our interviewers about a week ago. The call was about consumer attitudes toward health information exchange. I understand that you may have some concerns about the study that I might be able to address.

G. Privacy Manager / J. Answering Machine Message

Hello, my name is _______. I'm calling on behalf of the United States Department of Health and Human Services to conduct an important study of attitudes toward electronic health information exchange. Please call us at 1-XXX-XXX-XXXX at your convenience. Thank you.

H. Alternative Answering Machine/ L. Privacy Manager

(to be left in households where the screening process is complete and the CATI program has already selected an eligible respondent to interview in the household)

Hello, this message is for {fill name or initials of selected respondent]. My name is ________ and I'm calling on behalf of the United States Department of Health and Human Services in regards to an important study of attitudes toward electronic health information exchange (we recently spoke to you about/for which you may be eligible). Please call us at 1-XXX-XXX-XXXX at your convenience or we will try you again. Thank you.