Form 1.1 Survey

ATTACHMENT 2 IN PERSON SCREENING SCRIPT OMB NUMBER: 0925-XXXX

EXPIRATION DATE: XX/XX/XXXX

IN PERSON SCREENING SCRIPT

Hello, my name is ______________ from the department of Pediatrics at Johns Hopkins.

We are working on a research study about different things that can affect a mother and her child’s health. May I ask you some questions to see if you are eligible to participate?

NO:

Thank you for your time

YES:

I need to tell you that, I am going to write down the information you give me.

Your information will only be seen by researchers at Johns Hopkins. We try to make sure that the information we collect from you is kept private and used only for the research study we are discussing. If you do not want to speak with me any further, it will not affect your care at Johns Hopkins.

If you are not eligible or do not wish to participate you will have the option to let us keep your information on file so we can contact you about future opportunities. If you do not want us to keep this information we will destroy all documents with your name on them.

ADMINISTER SCREENING SHEET (separate document):

We will be asking some basic questions about your age, race/ethnicity, and income level.

IF NOT ELIGIBLE:

Unfortunately you are not eligible for this study, would like you me to keep you information on file and contact you at a later point?

YES:

Take down contact information

NO:

Thank you for your time.

IF ELIGIBLE:

You are eligible to participate in this study. If you wish to participate you will be asked to come in and complete a onetime interview with one of our researchers. During the interview we would ask you about your thoughts on some survey questions we are hoping to include in a larger national study. We are doing these interviews because we want to know if the survey questions are easy to understand and meaningful across different groups of people. The interview would take approximately 45 minutes to complete.

There are minimal risks to you if you choose to participate. You may get tired or bored during the interview or feel uncomfortable answering some of our questions. You participation is completely voluntary and you will have the right to refuse any of our questions.

There is no cost to you to participate in the study and you will be provided $25 in cash or gift card for your time.

• Do you have any questions?

• Do you think you would like to take part in this research?

YES:

Let’s make an appointment for your interview. You will meet with _____________ at __:__ AM/PM on _____________________. If you need to cancel or reschedule call ____________ at _________________.

NO:

Would like you me to keep you information on file and contact you at a later point?

YES:

Take down contact information

NO:

Thank you for your time.

Public reporting burden for this collection of information is estimated to3minutes 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-XXXX). Do not return the completed form to this address.