0920-0572 Testing of brand concepts Appendix A2-Screener-HCP

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

Health Care Professionals

Discussion Group Recruitment Screener – March—April 2013

• Recruitment: Recruit 4 for 3 to show for each HCP triad (3 physician triads and 3 non-physician triads for a total of 6 triads and up to 24 participants)

• Incentive: $50 per participant

• Duration: 60 minutes or less per triad

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. 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 health care professionals such as yourself on several topics. Everyone who is eligible and participates will receive a gift of $50.

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

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).

28a. What is your job title or role?

( ) Doctor (MD, DO) Continue

( ) Nurse Continue

( ) Nurse Practitioner Continue

( ) Physician’s Assistant Continue

( ) Registered Dietician Continue

( ) Other [Pharmacist or Certified Diabetes Educator] Continue

( ) Other Terminate

[Recruit half Doctor (MD, DO) and half mix of Nurse, NP, PA, Pharmacist, Certified Diabetes Educator, or RD]

30a. What is your primary specialty?

( ) Family Medicine Continue

( ) Internal Medicine Continue

( ) Obstetrics/Gynecology Continue (no

more than 2)

( ) Oncology Terminate

( ) Pathology Terminate

( ) Psychiatry Terminate

( ) Clinical Genetics Terminate

( ) Other (please specify):_________________ Terminate

29a(1). Describe your work environment:

( ) Less than 50% of time spent seeing patients 40 years of age and older Terminate

( ) 50% or more of time spent seeing patients 40 years of age and older Continue

29a(2). Describe your work environment:

( ) Rarely see patients with prediabetes or that are at risk for type 2 diabetes Terminate

( ) Commonly see patients with prediabetes or that are at risk for type 2 diabetes Continue

29a(3). Describe your work environment:

Approximately what percent of your patients are:

Ethnicity:

( ) 1. Hispanic or Latino Continue

( ) 2. Not Hispanic or Latino Continue

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

IF ONE-THIRD OF PATIENTS OVERALL DO NOT INCLUDE HISPANICS, OR BLACKS, OR AMERICAN INDIANS/ALASKA NATIVES, OR NATIVE HAWAIIANS/OTHER PACIFIC ISLANDERS THEN TERMINATE

42a. Most of the discussion will involve speaking and reading in English. Are you comfortable with speaking and reading in English?

( ) Yes Continue

( ) No Terminate

10a. What is your current occupational status? Would you say…?

( ) Employed full time Continue

( ) Employed part time Continue

( ) Unemployed Terminate

( ) Homemaker Terminate

( ) Student Terminate

( ) Retired, or Terminate

( ) Disabled Terminate

( ) Other: ______________ Terminate

( ) Don’t Know/Not Sure (DO NOT READ) Terminate

( ) Refused (DO NOT READ) Terminate

[Recruit a mix]

1a. Gender [Do not ask unless necessary]

( ) Male Continue

( ) Female Continue

[Recruit a mix]

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 3 other people and a moderator. The group will meet for about 60 minutes. To show appreciation for your participation you will get $50.

Scheduled Date: _____________________ Time: ______________________

[Confirm whether they will have a computer with reliable high-speed internet and a reliable phone connection to take part in the discussion remotely, and whether they feel comfortable doing this. If not, put on HOLD as potential focus group participant.]

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.

Health Care Professionals - Discussion Groups Recruitment Screener 1