Screener

Attachment 3

Screener for the Colorectal Cancer Population Survey

Form Approved

OMB No.: 0920-XXXX

Expiration Date: XX/XX/XXXX

Public reporting burden of this collection of information is estimated to average 5 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

Screener for the Colorectal Cancer Population Survey

Screener

• Ask ALL

INTRO1. Hello, my name is ____________ and I am calling from ICF International, an independent research firm. This is not a sales call. I’m calling on behalf of the Centers for Disease Control and Prevention conducting an important survey about the health of Americans. Is this a private residence?

01 Yes, continue

07 Termination screen

• if resumed interview and adults>1/

RINTRO1 Hello, this is NAME from ICF Macro. We recently started a survey about the health of Americans with the///INSERT SELECTED///in your household. May I please speak with the [INSERT SELECTED] in your household?

01 Yes, CONTINUE

05 [SELECTED] ON THE PHONE

07 TERMINATE SCREEN

• if resumed interview and adults=1

RINTRO2: Hello, this is NAME from ICF Macro. We recently started a survey about the health of Americans with the adult in your household. May I please speak with the adult who is 50 years of age or older?

01 Yes, CONTINUE

05 [SELECTED] ON THE PHONE

07 TERMINATE SCREEN

• /if intro1 in (02) /

X2 Thank you very much, but we are only interviewing private residences. Thank you for your time. //TERM //

• /ASK IF INTRO1=01

ADULTS I need to randomly select one adult aged 50 or over who lives in your household to be interviewed. How many members of your household, including yourself, are 50 years of age or older?

__ Number of adults aged 50 or older [RANGE 0-18]

• ask if adults=0/

ADULT0 You are saying there are NO adults 50 or over in your household.

Is that correct?

01 Yes, correct: NO adults 50 or over in household ///SKIP TO X3///

02 No, incorrect ///RESET TO ADULTS///

• /if adult0 =1/

X3 Thanks very much, but we are only interviewing adults 50 or over. ///TERM//

• if adults > 5

NOTE2 I am sorry. I just want to make sure I recorded this correctly. You said that there are //insert number from ADULTS// adults over 50 living in your household. Is that correct?

01 YES, CORRECT AS IS                                      

02 NO //RESET TO ADULTS//

• /ASK IF ADULTS=01/

ONEADULT Are you the adult age 50 or over?

21 YES AND THE RESPONDENT IS A MALE

22 YES AND THE RESPONDENT IS A FEMALE

03 NO

// IF ONEADULT = 03//

ASKGENDR    

  Is the Adult a man or a woman?

21 MALE

22 FEMALE

• create variable twoadlt If 2 adults in Household, then randomly select “1” or “2”. If twoadlt=1, then “the oldest adult over 50” is selected. If twoadlt=2, then “the youngest adult over 50” is selected.

• if twoadlt=01 OR 02

TWOADLT2. The person in your household that I need to speak with is the [INSERT SELECTED]. Are you that person?

[IF NECESSARY: The computer randomly selects the youngest or oldest person over 50 in the household. This way everyone has an equal chance of being included.]

01 yes, adult coming to phone [go to newadult]

02 yes, adult on phone [go to consent]

• INTERVIEWER NOTE] SUSPEND IF THE SELECTED RESPONDENT IS NOT AVAILABLE.

• /ASK IF ADULTS >2/

MEN How many of these adults over 50 are men?

___ ENTER RESPONSE ///RANGE 0 – 18///

• /ASK IF ADULTS >2/

WOMEN How many of these adults over 50 are women?

___ ENTER RESPONSE ///RANGE 0 – 18///

if oneadult HH set selected to 21; if twoadlt=01 set selected to 22, if twoadlt=02 set selected to 23; RANDOMLY SELECT ADULT; Assign Selected Value:

• 01 Oldest Female 50 or over

• 02 2nd Oldest Female 50 or over

• 03 3rd Oldest Female 50 or over

• 04 4th Oldest Female 50 or over

• 05 5th Oldest Female 50 or over

• 06 6th Oldest Female 50 or over

• 07 7th Oldest Female 50 or over

• 08 8th Oldest Female 50 or over

• 09 9th Oldest Female 50 or over

• 11 Oldest Male 50 or over

• 12 2nd Oldest Male 50 or over

• 13 3rd Oldest Male 50 or over

• 14 4th Oldest Male 50 or over

• 15 5th Oldest Male 50 or over

• 16 6th Oldest Male 50 or over

• 17 7th Oldest Male 50 or over

• 18 8th Oldest Male 50 or over

• 19 9th Oldest Male 50 or over

• 20 No respondent selected

• 21 One adult 50 or over '' Male

• 22 One adult 50 or over '' Female

• 24 oldest adult 50 or over

• 25 youngest adult 50 or over

• /ask if total number of men plus women is less than number recorded in adults/

SHOWTOT

I'm sorry, something is not right.

Number of Men - [INSERT NUMBER MEN]

Number of Women - [INSERT NUMBER WOMEN]

------

Number of Adults - [INSERT NUMBER OF ADULTS]

01 Correct the number of men

02 Correct the number of women

03 Correct the number of adults

• /ASK IF ADULTS >2/

ASKFOR The person in your household that I need to speak with is the

[INSERT SELECTED]

Are you the person?

01 Yes

02 No

• ask if ONEADuLT=02 OR askfor=02

GETADULT.  May I speak with him or her? 

1. Yes, Adult coming to the phone.

[INTERVIEWER NOTE: TYPE SUSPEND IF THE ADULT IS NOT AVAILABLE]

• //IF GETADULT = 01 OR TWOADLT2=01

NEWADULT. Hello, my name is ____________ and I am calling from ICF International, an independent research firm. This is not a sales call. I’m calling on behalf of the Centers for Disease Control and Prevention conducting an important survey about the health of Americans.

[INTERVIEWER NOTE: Type “suspend” if respondent does not want to continue]

001 Person Interested, continue.

• ask if NEWADULT=01 or ASKFOR=01 or oneadult=01 OR twoadlt2=02 OR RINTRO1=05 or rintro2=05

CONSENT. Let me tell you briefly about the survey. Your telephone number was chosen randomly. The survey is about colorectal cancer, which is an important health concern for many Americans. The CDC is interested in learning about your feelings, beliefs, and experiences so that they can help more people learn about and prevent colorectal cancer. In total, we will speak with about 4,800 people.

Taking part in this survey will take approximately 23 minutes. I will not ask for your name, address, or other personal information that can identify you. There is very little risk to you in taking part in the study. If I ask any questions you do not want to answer, tell me and I will skip them. Your participation in this survey is entirely voluntary, and you can stop at any time. Your answers to the survey questions will be maintained in a secure manner by ICF International. Although you may not directly benefit from answering our questions, the data we collect during this survey will help us learn how people feel about colorectal cancer screening.

If you have any questions, I can provide a telephone number—either here at ICF International or at the CDC—for you to call to get more information.

This interview may be monitored or recorded for quality assurance purposes. Before I begin the interview, do I have your verbal consent to participate in this study?

 [INTERVIEWER NOTE: Type “suspend” if respondent does not want to continue.]

01 Continue

02 RESPONDENT WANTS MORE INFORMATION

• ASK IF consent=02

Intro2b.

For questions about the survey, including inquires about administration, nature of the survey, or confidentiality, please contact Study Director Michelle Revels at 404-592-2156 or mrevels@icfi.com. If you have any concerns about the way you were treated during this interview you can also contact the Chair of ICF International Institutional Review Board (IRB), Janet Griffith at 703-225-2243 or JGriffith@icfi.com.

 [INTERVIEWER NOTE: Type “suspend” if respondent does not want to continue.]

01 Continue