Screener

Form Approved

OMB No. 0920-1027

Expiration Date 08/31/2017

2015 CDC Hep C Campaign Testing

Baby Boomer Segment Recruiting Screener

Attachment 1

Public reporting burden of this collection of information is estimated to average 10 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: OMB-PRA (0920-1027)

Hepatitis C Awareness/Material Testing Telephone Screening Instrument

Greeting for people who are called:

Hello, my name is I’m with , a local opinion research company. We are working on a project for the Centers for Disease Control and Prevention, or CDC, part of the nation’s public health service and the sponsor of this market research study. CDC is interested in talking with small groups of people to get feedback on some educational materials and advertisements on a specific health topic. Each group will meet for about two hours.

May I ask you a few questions to see if you qualify to participate in one of these groups? Your responses will be private.

1. Record gender

1 Male

2 Female

2. Have you or your partner or spouse ever worked or volunteered for any of the following types of organizations? [Terminate all]

1. Marketing, advertising or public relations agency or department

2. Health care facility, such as a hospital, HMO, doctor’s office, or clinic

3. Professional medical association, pharmaceutical, or drug company

4. City, state or other type of health department

5. Other health-related organization, school, or agency (such as a nursing school, local AIDS organization, American Cancer Society)

3a. Please indicate your race or ethnic background. Are you….?

SELECT ONE

Ethnicity

1. Hispanic or Latino

2 Not Hispanic or Latino

SELECT ONE OR MORE

Race:

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Native Hawaiian or Other Pacific Islander

5. Asian

4. What year you were born? _____________________ [record]

1944 and earlier [Terminate]

1945 – 1965 [Continue}

1966 and later [Terminate]

5. Do you currently receive medical care from the VA or Veterans Administration?

1 Yes [Terminate]

2 No CONTINUE

3 Don’t know CONTINUE

6. Do you have health insurance or participate in a health plan that covers routine visits to the doctor?

1 Yes Continue

If yes: What is the name or your plan or plans? ________________________________________

2 No [Terminate]

3 Don’t know [Terminate]

4 Medicaid [Terminate]

7. In the last year, have you ever gotten a blood test for?

1. Diabetes CONTINUE

2. Cholesterol CONTINUE

3. Hepatitis [Terminate]

4. STD CONTINUE

5. HIV CONTINUE

8a. Have you ever been told by a doctor or other health professional that you have or have had any of the following:

1. Diabetes [information only]

2. Heart attack, also known as an MI or myocardial infarction. [information only]

3. Cancer,

If yes, which kind? [Terminate for all cancers except skin].

4. HIV or AIDS [Terminate]

5. Hepatitis [Terminate]

8b. Have you or anyone in your immediate family or household ever had liver disease, cirrhosis or liver cancer?

1 No Continue

2. Yes [Terminate]

9a. Do you currently have a doctor or health professional that you see regularly for routine check-ups or annual exams and other preventive health issues?

1 Yes Continue

2 No [Terminate]

9b. If yes: When was the last time you saw a doctor or health care provider for a physical or annual exam? Was it…. [Read list]

1 Within the last 6 months

2 Within the last year

3 Within the last 2 years

4 More than 2 years ago terminate

RECRUITER: HIGHEST PRIORITY is for routine physical within the last 6 months.

10. When, if ever, was the last time you participated in a focus group?

1 Have never participated Continue

2 Within the last 12 months: What was the topic: ________________________

[Continue screening, but do not recruit if topic was health-related without client approval.]

3. More than 12 months ago: Continue

11. What is the highest grade of school you completed? [Read list;]

1 Less than high school [Terminate]

2 Some high school

3 Completion of high school

4 Some college

5 Completion of college

6 Post-graduate degree

12. We want to be sure we represent a broad range of people in this market research study and have one last question for statistical purposes. Please stop me when I read the range that includes your total annual household income. [Information only]

1. Less than or equal to $__59,000__________

2. More than $_59,000_____; less than or equal to $ _100,000____

3. More than $100,000

4. Refused: OK to continue if respondent refuses but otherwise qualifies.

INVITATION:

Thank you. We would like to invite you to participate in a group discussion about some health related advertising. The discussion will take place at a convenient office location, and will last for about 2 hours. Refreshments will be served. The discussion will take place at [LOCATION, DATE AND TIME]. This discussion is strictly for improving public service educational materials and we are not trying to sell you anything, we are only interested in your opinions. Are you willing to participate?

If yes, we will mail you a confirmation, and call you the day before you are to come to remind you of your appointment. However, if you know in advance that you will have to cancel, please be sure to call us at _____.