Attachment E
Pediatrician Screener
Form Approved
OMB No. 0920-0572
Expiration Date: 2/28/2015
Public
Reporting burden of this collection
of information is estimated at 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 NW, MS D-74, Atlanta, GA 30333; Attn:
PRA (0920-0572).
Screener/Pediatricians
CDC “Parents are the Key” Toolkit Materials Evaluation
10-MINUTE ASSESSMENT TO RECRUIT FOR ONLINE FOCUS GROUPS
(INTRO) We would like to invite you to participate in an online group discussion [INSERT DATE]. The group session will last for approximately 60 minutes and will be conducted in English.
The session is being sponsored by the Centers for Disease Control and Prevention and is focused on a communications campaign about safe teen driving. The campaign highlights the message that motor vehicle crashes are the leading cause of death among teens, but there are proven steps that parents can take to help keep teens safer on the road.
To express our appreciation for assisting us with your insights, we will offer a $75 gift for participation. But, first I'd like to ask you a few questions for background information to see if you qualify for this project. [TYPE: Static]
Overview:
20-25-person online focus group: 60 minute session
All will be:
Pediatricians in practice for at least 2 years
Clinicians consulting with patients at least weekly
Pediatricians with at least 20% of patients being teens (13-18 years old)
Recruit a range of:
Age
Gender
Geography
(RECRUIT1) Would you be available to participate in an online focus group on the day/time listed below? [TYPE: Multiple Choice]
1: |
Yes, I would like to participate on [INSERT DATE & TIME] |
2: |
No [TERMINATE] |
(S1. DEMOGRAPHICS GENDER) Are you... [TYPE: Multiple
Choice] |
1: |
Male |
2: |
Female |
(S2.
DEMOGRAPHICS AGE) What is your approximate age? [TYPE: Multiple
Choice]
1: |
18-24 years [TERMINATE] |
2: |
25-29 years [TERMINATE] |
3: |
30-34 years |
4: |
35-39 years |
5: |
40-44 years |
6: |
45-49 years |
7: |
50-54 years |
8: |
55-59 years |
9: |
60-64 years |
10: |
65-69 years |
11: |
70-74 years |
12: |
75 and over [TERMINATE] |
(S3. DEMOGRAPHICS AREA EMPLOY) You previously indicated that you are a physician in the healthcare industry. Which of the following best describes your specialty? [TYPE: Multiple Choice]
1: |
General practitioner [TERMINATE] |
2: |
Family physician [TERMINATE] |
3: |
Pediatrician |
4: |
Nurse practitioner [TERMINATE] |
5: |
Psychiatrist / Psychologist [TERMINATE] |
9: |
Other [TERMINATE] |
(S4.
DEMOGRAPHICS CLINICIAN) Which of the following best describes
your current job ... [TYPE: Multiple Choice]
1: |
Clinician operating private practice |
2: |
Clinician working for group practice |
3: |
Clinician working for a hospital or clinic |
4: |
Researcher – clinical [TERMINATE] |
5: |
Other (please specify) |
(S5.
DEMOGRAPHICS YEARS IN PRACTICE) How long have you been a
practicing doctor? [TYPE: Multiple Choice]
1: |
1 year or less [TERMINATE] |
2: |
2 to 5 years |
3: |
6 to 10 years |
4: |
11 to 15 years |
5: |
16+ years |
(S6.
DEMOGRAPHICS CONSULT) How often do you consult with patients?
[TYPE: Multiple Choice]
1: |
Daily |
2: |
Weekly |
3: |
Monthly [TERMINATE] |
4: |
Less than once per month [TERMINATE] |
(S7. DEMOGRAPHICS AGE OF PATIENTS) What percentage of your patients fall into each of the below age groups? [TYPE: Must add up to 100%]
1: |
Under 5 |
_____% |
2: |
6-12 years old |
_____% |
3: |
13-18 years old |
_____%[TERMINATE if less than 20%] |
4: |
19 and older |
_____% |
(S8. DEMOGRAPHICS STATE) What state do you reside in? [TYPE: Multiple Choice]
1: |
Alabama |
2: |
Alaska |
3: |
Arizona |
4: |
Arkansas |
5: |
California |
6: |
Colorado |
7: |
Connecticut |
8: |
Delaware |
9: |
District of Columbia |
10: |
Florida |
11: |
Georgia |
12: |
Hawaii |
13: |
Idaho |
14: |
Illinois |
15: |
Indiana |
16: |
Iowa |
17: |
Kansas |
18: |
Kentucky |
19: |
Louisiana |
20: |
Maine |
21: |
Maryland |
22: |
Massachusetts |
23: |
Michigan |
24: |
Minnesota |
25: |
Mississippi |
26: |
Missouri |
27: |
Montana |
28: |
Nebraska |
29: |
Nevada |
30: |
New Hampshire |
31: |
New Jersey |
32: |
New Mexico |
33: |
New York |
34: |
North Carolina |
35: |
North Dakota |
36: |
Ohio |
37: |
Oklahoma |
38: |
Oregon |
39: |
Pennsylvania |
40: |
Rhode Island |
41: |
South Carolina |
42: |
South Dakota |
43: |
Tennessee |
44: |
Texas |
45: |
Utah |
46: |
Vermont |
47: |
Virginia |
48: |
Washington |
49: |
West Virginia |
50: |
Wisconsin |
51: |
Wyoming |
(FLASH
CHECK) You will need to have the Flash player installed on your
system in order to join the live session.
Please
click here to make sure you have Flash.
If
you do not, then follow the instructions to install Flash and return
to this page. If you do, then select 'Yes' below and click the Next
button. [TYPE: Multiple Choice]
1: |
Yes, I have Flash! |
2: |
No [TERMINATE] |
(CONNECTION CHECK) What type of internet connection do you currently have on the computer you will be using to participate in the online discussion session? [TYPE: Multiple Choice]
1: |
Dial-up connection [TERMINATE] |
2: |
Broadband connection (e.g., cable, DSL, Fios, etc.) |
(THURS RECRUIT) Congratulations! You have agreed to participate in a live online session on ...
|
Prior to the session, you will receive an email confirmation from 'Stratalys Research' with a link and instructions for logging into the session.
You may log in up to 20 minutes before the start time of the session. You will not be allowed into the session if you log in late.
You may participate from any desktop or laptop computer.
NOTE: Please make sure you can devote the entire 60 minutes to the session. You must complete the entire session in order to receive your reward. Also, please try to ensure that you are able to focus on the session by eliminating any distractions.
Please confirm that you will be participating by selecting 'Yes' below...
[TYPE: Multiple Choice]
1: |
Yes, I'll be participating |
2: |
No [TERMINATE] |
(COMPLETE)
Thank you for completing the online focus group registration! You
will receive an email with login information on the day of the
session. We look forward to your participation. Please click on the
link below to submit your answers...
[TYPE: Static]
(OVERQUOTA)
Thank you for participating! We needed a specific number of people to
take part in the discussion session, and we have already exceeded
that number! Although we have reached our limit for the group
session, we appreciate your time.
Please click on the link
below to submit your answers...
[TYPE: Static]
(TERMINATE)
Thank you for participating! Although you did not qualify for this
study, we appreciate your time. Thanks again!
Please
click on the link below to submit your answers...
[TYPE: Static]
www.stratalys.com
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Jeffrey Hayes |
File Modified | 0000-00-00 |
File Created | 2021-01-25 |