Audience Research on Self-Management Education
Attachment 2 to the HMTS Expedited Review Form
Form Approved
OMB No. 0920-0572
Exp. Date: 2/28/2015
Attachment 2: Eligibility Screener
Audience Research on Self-Management Education
Attachment 2 to the HMTS Expedited Review Form
May 16, 2013
FHI 360 - Centers for Disease Control and Prevention
Table 1: Phase I - Summary Table
Group |
Location |
Date/Time |
Audience |
#1 |
Richmond, Virginia |
5:30 PM |
Women with 1 or more chronic conditions |
#2 |
Richmond, Virginia |
7:30 PM |
Men with 1 or more chronic conditions |
#3 |
Chicago, Illinois |
5:30 PM |
Women with 1 or more chronic conditions |
#4 |
Chicago, Illinois |
7:30 PM |
Men with 1 or more chronic conditions |
#5 |
Phoenix, Arizona |
5:30 PM |
Women with 1 or more chronic conditions |
#6 |
Phoenix, Arizona |
7:30 PM |
Men with 1 or more chronic conditions |
Table 1: Phase II - Summary Table
Group |
Location |
Date/Time |
Audience |
#1 |
Atlanta, Georgia |
5:30 PM |
Women with 1 or more chronic conditions |
#2 |
Atlanta, Georgia |
7:30 PM |
Men with 1 or more chronic conditions |
#3 |
Houston, Texas |
5:30 PM |
Women with 1 or more chronic conditions |
#4 |
Houston, Texas |
7:30 PM |
Men with 1 or more chronic conditions |
#5 |
Des Moines, Iowa |
5:30 PM |
Women with 1 or more chronic conditions |
#6 |
Des Moines, Iowa |
7:30 PM |
Men with 1 or more chronic conditions |
Public
Reporting Burden Statement 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 Information Collection Review Office, 1600 Clifton Road
NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0572).
Recruitment:
(For each focus group, recruit 10 for 8 participants to show)
[Request to speak with an adult in the household.]
Hello, I’m _______________. I work for _____________________, an independent research firm. We are doing a study for the Centers for Disease Control and Prevention, also known as the CDC, to find out what people think about some of the information that they plan to share with the public and to get input regarding messages about programs for ongoing health problems. We are looking for people to take part in discussion groups about these topics. Input and ideas from these discussions will help inform CDC about information that will be useful to the public. We are not selling any product or service. Everyone who is eligible and participates will receive $50 as a thank you for their time.
The discussion groups will be held on [Dates] at [Place] and will last about 90 minutes. I would like to ask you some questions to see if there is a discussion group that you could join. These questions will only take a few moments to answer.
Some of the questions I am about to ask you are about your health. These questions may feel personal and sensitive. You do not have to answer any question if you don’t feel comfortable, and you may stop at any time. Do you have time now to answer a few questions?
May I continue with my questions?
[Record gender—ask if unsure]
( ) Female
( ) Male
[Recruit a mix over time]
Have you participated in a focus group, intercept interview, telephone survey, and/or online survey in which you were asked your opinions regarding a product, a service, or advertising within the past six months?
( ) Yes <<Terminate
( ) No
Do you, or does any member of your household or immediate family work for: [Read each statement below]
( ) a market research company <<Terminate
( ) an advertising agency or public relations firm <<Terminate
( ) the media (TV/radio/newspapers/magazines) <<Terminate
( ) as a healthcare professional (doctor, nurse, pharmacist, dietician, etc.) <<Terminate
Terminate >> If any YES
[Continue only if none of the above employment situations are marked.]
In which of the following categories does your age fall:
( ) under 18 years of age <<Terminate
( ) 18-24 years of age <<Terminate
( ) 25-34 years of age <<Terminate
( ) 35-44 years of age <<Terminate
( ) 45-54 years of age
( ) 55-64 years of age
( ) 65-75 years of age
( ) 76 years of age or older <<Terminate
[Only recruit participants who are 45-75 years of age.]
Have you EVER been told by a doctor or other health professional that you had…
5a. [Asthma]?
( ) Yes
( ) No
( ) [Do not read; record only] Refuse/Don’t Know
5b. [Arthritis]?
( ) Yes
( ) No
( ) [Do not read; record only] Refuse/Don’t Know
5c. [Diabetes]?
( ) Yes
( ) No
( ) [Do not read; record only] Refuse/Don’t Know
5d. [Heart Disease]?
( ) Yes
( ) No
( ) [Do not read; record only] Refuse/Don’t Know
[Terminate if “No” or “Refuse/Don’t Know” to all 5a-d. Recruit a mix for each group. Recruit at least 2 participants with each chronic condition or ongoing health problem for all groups.]
[As appropriate, repeat and record for each chronic condition or ongoing health problem]: For how long have you had [arthritis/asthma/diabetes/heart disease]?
Asthma:___ years
Arthritis:___ years
Diabetes:___ years
Heart Disease:___ years
[Record number of chronic conditions or ongoing health problems:]
( ) 1 chronic condition or ongoing health problem
( ) More than 1 chronic condition or ongoing health problem
[Recruit a mix in each segment. Recruit at least 3 participants per group with only 1 ongoing health problem.]
Thinking about your [ongoing health problem or problems], which of the following best describes you TODAY?
( ) I can do everything I want to do. <<Terminate
( ) I can do most of the things I want to do, but I have some limitations.
( ) I can do some, but not all of the things I want to do, and I have many limitations.
( ) I can hardly do any of the things I want to do. <<Terminate
( ) [Do not read; record only] Don’t’ Know <<Terminate
On a scale from 1 to 5, where 1 indicates that you strongly disagree, and 5 indicates that you strongly agree, please tell me the number which indicates how much you agree or disagree with each statement.
9a.I have thought about taking action to [do something about my ongoing health problem].
( ) 1 Strongly Disagree <<Terminate
( ) 2
( ) 3
( ) 4
( ) 5 Strongly Agree
9b. I am taking action to [manage my ongoing health problem through participation in a self-management program] right now.
( ) 1 Strongly Disagree
( ) 2
( ) 3
( ) 4 <<Terminate
( ) 5 Strongly Agree <<Terminate
Do you consider yourself Hispanic or Latino?
( ) Hispanic or Latino
( ) Not Hispanic or Latino
Please tell me your race or ethnic background. Please select one or more.
( ) American Indian or Alaska Native
( ) Asian
( ) Black or African American
( ) Native Hawaiian or Other Pacific Islander
( ) White
[Recruit a mix over time – AI/AN, Asian, and NH/PI not critical to recruit]
What is the highest level of education you have completed?
( ) Grade school
( ) Less than high school graduate/some high school
( ) High school graduate or completed GED
( ) Some college or technical school degree
( ) Received four-year college degree
( ) Some post graduate studies
( ) Received advanced degree
( ) Other: _____________________
( ) [Do not read; record only] Refuse <<Terminate
[Recruit a mix of college degree or more and less than college degree. Limit recruitment of some post graduate studies and received advanced degree to no more than 2 individuals per group.]
Which of the following categories best describe your total annual household income?
( ) Under $20,000/year
( ) $20,001 - $30,000/year
( ) $30,001 - $40,000/year
( ) $40,001 - $50,000/year
( ) $50,001 - $60,000/year
( ) $60,001 - $80,000/year
( ) $80,001 - $100,000/year
( ) Over $100,000/year
[Recruit a mix in each segment. Limit recruitment of individuals with income over local median income to no more than 3 participants per group.]
Phase I:
City |
Richmond, VA |
Chicago, IL |
Phoenix, AZ |
Median Income |
$39,201 |
$47,371 |
$48,596 |
Limit Recruitment of: |
>$40,000/year |
>$50,000/year |
>$50,000/year |
Phase II:
City |
Atlanta, GA |
Houston, TX |
Des Moines, IA |
Median Income |
$45,946 |
$44,124 |
$44,997 |
Limit Recruitment of: |
>$50,000/year |
>$50,000/year |
>$50,000/year |
**TERMINATE LANGUAGE: Thank you very much for your time. We have recruited all of the persons like you that we need to talk to, so we won’t be able to include you in our study. Thank you for your time and interest. Have a good day/evening.
INVITE TO INTERVIEW
Thank you for answering my questions. As I mentioned this study is being conducted on behalf of the Centers for Disease Control and Prevention about themes and messages about chronic disease management, and we would like to include your views.
In order for us to get your input, I would like to invite you to participate in focus group. The focus group will last about 90 minutes and will take place at ________________ on day/time _______________.
This is not a sales effort of any kind and no one will call on you as a result if your participation. To compensate you for your time and travel expenses, you will receive $50. Can we schedule your participation?
Check day and time; see details below.
NAME: _________________________________________________
ADDRESS: _________________________________________________
CITY: _________________________________________________
ZIP CODE: _________________________________________________
PHONE: (DAY) _____________________________________
(EVE) _____________________________________
(CELL) _____________________________________
(EMAIL) _____________________________________
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | AED - Centers for Disease Control and Prevention |
Author | tlehman |
File Modified | 0000-00-00 |
File Created | 2021-01-25 |