Chronic Fatigue Syndrome: Symptoms from the Patient Perspective

Attachment 5: CFS Patient Perspective Focus Group Screener

Chronic Fatigue Syndrome (CFS): Symptoms from the Patient Perspective

Denver: XX 2015

Group 1 at XXam-XXpm

Group 2 at XXpm-XXpm

Orange County: XX 2015

Group 1 at XXam-XXpm

Group 2 at XXpm-XXpm

RECRUIT 12 for 8-10 to show per group.

Hello, I'm _______________________ from Fieldwork, an independent marketing research firm. We're conducting focus groups on behalf of the Centers for Disease Control and Prevention (CDC) and we would like to include your opinions. Let me assure you we are not trying to sell you anything nor will you be contacted in the future as a result of your participation. All information will remain confidential. May I ask you a few questions please?

1. When was the last time you participated in a group discussion or individual interview for marketing research, for something other than political reasons? DO NOT READ LIST

Never [ ] CONTINUE

Within the past 6 months [ ] TERMINATE & TALLY

Longer than 6 months ago [ ] CONTINUE

2. Do you or does any other member of your household work for?

[ ] An advertising agency [ ] A public relations firm

[ ] A marketing research firm [ ] Any news media (TV, radio, publications, etc)?

[ ] A chronic fatigue syndrome patient organization

[ ] A chronic fatigue syndrome physician or medical office

IF YES TO ANY OF THE ABOVE - THANK & TERMINATE

3. Which of the following age categories do you fall under? READ LIST

Under 18 [ ] TERMINATE

18 – 29 [ ] CONTINUE

30 – 39 [ ] CONTINUE

40 – 55 [ ] CONTINUE

56 or above [ ] TERMINATE

4. Have you ever been told by a doctor or other health professional that you had Chronic Fatigue Syndrome (CFS) or Myalgic Encephalomyelitis (ME)?

No [ ] TERMINATE

Don’t know [ ] TERMINATE

Yes [ ] CONTINUE

5. Do you still have Chronic Fatigue Syndrome (CFS) or Myalgic Encephalomyelitis (ME)?

No [ ] TERMINATE

Don’t know [ ] TERMINATE

Yes [ ] CONTINUE

6. Please list the top three treatments, medications or management techniques that have impacted your health since going to your doctor for Chronic Fatigue Syndrome (CFS) or Myalgic Encephalomyelitis (ME)?

   1. _______________________________________________________________________

   2. _______________________________________________________________________

   3. _______________________________________________________________________

(Answers include medication names, self-management, graded exercise therapy (GET), pacing, cognitive behavioral therapy (CBT)).

Your responses were very helpful, thank you. We are conducting a series of focus groups and would like you to participate. The discussion group is taking place at [LOCATION] on [DATE] at [TIME]. It will last approximately 2 hours, and in order to thank you and defer the cost of parking and travel, you will receive a reimbursement of $50. As I mentioned earlier, no one is trying to sell you anything - we are simply trying to learn from people and get their thoughts and opinions about CFS/ME. Would you be willing to participate and share your opinions with us?

Yes [ ] CONTINUE

No [ ] THANK & TERMINATE

During the discussion, you may be asked to view and read things both up close and at a distance. Is there any reason that you would not be able to participate in the activities?

Yes [ ] THANK & TERMINATE

No [ ] CONTINUE

If you wear glasses for reading, please be sure to bring them with you.

Name: _________________________________________________

Address: _______________________________________________

City: ________________________State __________ Zip: ________

Telephone number: _______________________________________

Alternative number: _______________________________________

E-mail: _________________________________________________

Interviewer's Pledge:

I hereby certify that the information contained in this document was obtained by me from the respondent listed above and that all the information contained herein is true and correct. I also certify that this respondent is unknown to me, and to any employee of ___________________.

___________________________________.

Field Service

__________________________________

Interviewer's Full Signature

___________________________________

Date

______________________________________

Supervisor's Full Signature

______________________________________

Date

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