Appendix
A: Screening Instruments Form
Approved
OMB
No. 0920-0572
Expiration
Date: 2/28/2015
Testing of Brand Concepts, Messages and Materials for CDC’s National Diabetes Prevention Program
Recruitment: Recruit 10 general public members for 8 participants to show for each focus group (total = 30 participants per market; 120 overall)
Incentive: $50 per participant
Duration: 1.5 hours or less per consumer focus group
Introduction
Hello, my name is ________ and I am calling from __________________, a marketing research firm in the ________________ area. I know you receive a lot of telephone calls from telemarketers, but I assure you, this is not a sales call. I am calling today to see if you might qualify to participate in a discussion group. Everyone who is eligible and participates will receive a gift of $50. The research study is sponsored by the Centers for Disease Control and Prevention, also known as the CDC. We are interested in hearing the opinions of people in our community on several topics.
May I please ask you a few questions? Thank you.
Screens
1b. Do you, or does any member of your household or immediate family work for:
( ) 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.)…………………………..…... Continue if not self
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).
2b. 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 Continue to 44a
44a(1). Do you have [prediabetes]?
( ) Yes …………………………………….. …Continue [Skip to Q6a]
( ) No Continue to 16f
16f. Are you planning to be physical active, or exercise, at least 3 times a week in the next 30 days?
( ) Yes Continue
( ) No Continue
How tall are you? __________ feet _______________ inches
[Ask the person if he or she weighs more than the weight in pounds that is given directly to the right of the height.]
Do you weigh more than __________ pounds?”
( ) Yes …………………………………….. …Continue
( ) No …………………………………….. …Continue
Height |
Weight in Pounds |
4’10” |
129 |
4’11” |
133 |
5’0” |
138 |
5’1” |
143 |
5’2” |
147 |
5’3” |
152 |
5’4” |
157 |
5’5” |
162 |
5’6” |
167 |
5’7” |
172 |
5’8” |
177 |
5’9” |
182 |
5’10” |
188 |
5’11” |
193 |
6’0” |
199 |
6’1” |
204 |
6’2” |
210 |
6’3” |
216 |
6’4” |
221 |
44a(2). Do you have:
[…a parent, sister, or brother with diabetes?]
( ) Yes Continue
( ) No Continue
[…(females only) a personal health history of gestational diabetes, or diabetes while pregnant?]
( ) Yes Continue
( ) No Continue
[…(females only) a personal health history of giving birth to a baby weighing 9 or more pounds?]
( ) Yes Continue to Q6a
( ) No Continue to Q6a
6a. Please indicate your race or ethnic background. Are you?
Ethnicity:
( ) 1. Hispanic or Latino Continue
( ) 2. Not Hispanic or Latino Continue
SELECT ONE OR MORE.
Race:
( ) 1. White Continue
( ) 2. Black or African-American Continue
( ) 3. American Indian or Alaska Native Continue
( ) 4. Native Hawaiian or Other Pacific Islander Continue
( ) 5. Asian Continue
[Continue only if 44a(1)=Yes, OR 16f=No, OR At-Risk Weight=Yes, OR any 44a(2)=Yes, OR 6a Ethnicity=Hispanic or Latino, OR 6a Race=Black or African American, Native Hawaiian or Other Pacific Islander, or American Indian or Alaska Native]
[Attempt to recruit even mix by race/ethnicity (Hispanics, AA, Caucasians/Others across groups]
4a. What is the highest level of education you have completed?
( ) Grade school Terminate
( ) Less than high school graduate/some high school Terminate
( ) High school graduate or completed GED Continue
( ) Some college or technical school Continue
( ) Received four-year college degree Continue
( ) Some post graduate studies Continue
( ) Received advanced degree Terminate
( ) Other: _____________________ …………………………………………….. Terminate
[Focus Groups: Recruit a mix in each segment]
25a. What is your age? _______________ (record age) [Terminate if not age 40 to 65]
[Recruit a mix in each segment]
13a. Which of the following categories best describe your total, annual household income?
( ) Under $20,000/year Terminate
( ) $20,001 - $30,000/year Continue
( ) $30,001 - $40,000/year Continue
( ) $40,001 - $50,000/year Continue
( ) $50,001 - $60,000/year Continue
( ) $60,001 - $80,000/year Continue
( ) $80,001 - $100,000/year Terminate
( ) Over $100,000/year Terminate
[Recruit a mix in each segment]
10a. What is your current occupational status? Would you say…?
( ) Employed full time Continue
( ) Employed part time Continue
( ) Unemployed Continue
( ) Homemaker Continue
( ) Student Continue
( ) Retired, or Continue
( ) Disabled Continue
( ) Other: ______________ Continue
( ) Don’t Know/Not Sure (DO NOT READ) Continue
( ) Refused (DO NOT READ) Continue
[Recruit a mix in each segment]
1a.
Gender
[Do
not ask unless necessary]
( ) Male Continue
( ) Female Continue
[Recruit about half male and half female in each segment]
12a. What is your marital status?
( ) Married Continue
( ) Unmarried living with a partner Continue
( ) Divorced Continue
( ) Widowed Continue
( ) Separated, or Continue
( ) Single, never been married Continue
( ) Don’t Know/Not Sure (DO NOT READ) Continue
( ) Refused (DO NOT READ) Continue
[Recruit mix in each segment]
INVITATION
Thank you for answering my questions. I would like to tell you a little more about the discussion group. The group will meet on [Date(s) available at [Time(s) available] at [Describe remote process]. You will join up to 9 other people and a moderator. The group will meet for about 90 minutes. To show appreciation for your participation you will get $50.
Scheduled Date: _____________________ Time: ______________________
If you wear reading glasses or use a hearing aid, please remember to have them with you for the discussion.
Before we hang up, let me get the correct spelling of your name, and your address and phone numbers so we can send you a letter with directions and give you a reminder call the day of the group.
FULL NAME ____________________________________________
ADDRESS ____________________________________________
____________________________________________
E-MAIL ____________________________________________
CELL PHONE ____________________________________________
HOME PHONE____________________________________________
WORK PHONE____________________________________________
I must let you know that we do consider this to be a firm commitment on your part and we really expect to see you then. We are under obligation to our client to seat the correct number of participants in each group, so if you discover that you must cancel, please inform us at once so that we can replace you.
We will call/email you a day or two before your session just to confirm everything. Thank you again for your time and we will see you at the group.
Consumer
Discussion Groups Recruitment Screener
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 |