ATTACHMENT C: Screening Instrument
Radiation Risk Scale
Form
Approved
OMB No. 0920-0572
Exp. Date 02/28/2015
Summary Table
Group |
Location |
Date/Time |
Audience |
#1 |
Atlanta, Georgia |
TBD ~3:30 |
Public |
#2 |
Atlanta, Georgia |
TBD ~6:00 |
Public |
#3 |
Atlanta, Georgia |
TBD ~8:00 |
Public |
Group |
Location |
Date/Time |
Audience |
#4 |
St. Louis, Missouri |
TBD ~3:30 |
Public |
#5 |
St. Louis, Missouri |
TBD ~6:00 |
Public |
#6 |
St. Louis, Missouri |
TBD ~8:00 |
Public |
Group |
Location |
Date/Time |
Audience |
#7 |
Houston, Texas |
TBD ~3:30 |
Public |
#8 |
Houston, Texas |
TBD ~6:00 |
Public |
#9 |
Houston, Texas |
TBD ~8:00 |
Public |
Group |
Location |
Date/Time |
Audience |
#10 |
Phoenix, Arizona |
TBD ~3:30 |
Public |
#11 |
Phoenix, Arizona |
TBD ~6:00 |
Public |
#12 |
Phoenix, Arizona |
TBD ~8:00 |
Public |
Recruit
3 groups per city
3:30 – 5:00 pm local time First Focus Group
6:00 – 7:30 pm local time Second Focus Group
8:00 – 9:30 pm local time Third Focus Group
Recruit 8 per group
Public
Recruitment: Recruit 8 participants; 6- 8 participants to show for each group (total = 40 participants per market)
Incentive: $40 for each participant, who participate in focus group
Duration: 90 minutes for each session
______________________________________________________________________________
Form
Approved
OMB No. 0920-0572
Exp. Date 02/28/2015
Good evening. My name is __________________ and I am calling from _______________, a market research firm. Today we are talking with people as part of a study for the Centers for Disease Control and Prevention. We are not selling anything. We have a few brief questions that will take just 15 minutes of your time, and if you qualify and are interested, we will invite you to take part in a discussion group with other people in your area that will take place at a later date.
In which of the following categories does your age fall? (A.2.a)
01 under 18 years of age [THANK AND TERMINATE]
02 18-24 years of age
03 25-34 years of age
04 35-44 years of age
05 45-54 years of age
06 55-64 years of age
07 65-74 years of age
08 75 years of age or older
[DOCUMENT ON GRID]
[RECRUIT A MIX WITHIN EACH GROUP]
[RECRUIT SO THAT GROUPS TOGETHER ARE REFLECTIVE OF THE COMMUNITY]
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? (B.2.b)
01 Yes [THANK AND TERMINATE]
No
Public
reporting burden of this collection of information is estimated to
average 15 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).
Do you, or does any member of your household or immediate family work (B.1.b):
01 For a market research company
02 For an advertising agency or public relations firm
03 In the media (TV/radio/newspapers/magazines)
04 As a healthcare professional (doctor, nurse, pharmacist, dietician, etc.)
[IF YES TO ANY, THANK AND TERMINATE]
What is your current job title? What term would you use to describe your current profession? (A.11.a)________________________________________
[IF ANY OF THE FOLLOWING, THANK AND TERMINATE
Employee of U.S. Department of Health and Human Services
Employee of state or local health department
Employee of Department of Homeland Security
Employee of state or local emergency management agency
Nuclear power plant employee, Radiation Safety Officer, health physicist or other radiation-related occupation
What is the highest level of education you have completed? (A.4.a)
01 Grade school [THANK AND TERMINATE]
02 Less than high school graduate/some high school
03 High school graduate or completed GED
04 Some college or technical school
05 Received four-year college degree
06 Some post graduate studies
07 Received advanced degree
08 Other: _____________________
[DOCUMENT ON GRID]
[RECRUIT A MIX WITHIN EACH GROUP]
[RECRUIT SO THAT GROUPS TOGETHER ARE REFLECTIVE OF THE COMMUNITY]
Gender (A.1.a)
01 Male
02 Female
[DOCUMENT ON GRID]
[RECRUIT ABOUT A 50/50 MIX]
[DOCUMENT ON GRID]
|
Categories |
a. ____ No, not of Hispanic, Latino/a, or Spanish origin (SKIP TO QUESTION 8) |
b. ____ Yes, Mexican, Mexican American, Chicano/a |
c. ____ Yes, Puerto Rican |
d. ____ Yes, Cuban |
e. ____ Yes, Another Hispanic, Latino/a or Spanish origin |
a. ____ White |
b. ____ Black or African American |
c. ____ American Indian or Alaska Native |
d. ____ Asian Indian |
e. ____ Chinese |
f. ____ Filipino |
g. ____ Japanese |
h. ____ Korean |
i. ____ Vietnamese |
j. ____ Other Asian |
k. ____ Native Hawaiian |
l. ____ Guamanian or Chamorro |
m. ____ Samoan |
n. ____ Other Pacific Islander |
[RECRUIT A MIX]
[DOCUMENT ON GRID]
Number of children (under the age of 18) living in your household? (A.14.a)
01 None
02 1-2 children
03 3-4 children
04 5 or more children
[DOCUMENT ON GRID]
[NOT A SCREENING CRITERION]
ASSESS AND VERIFY ABILITY TO SPEAK AND UNDERSTAND ENGLISH
Those are all of my questions. You do qualify for our discussion group and we would like to invite you to join us on _______ at ______ PM. The discussion will last about 90 minutes; it will be recorded (audio only) to be sure we get all the information. In appreciation for your time, you will be given $40 at the time of the discussion.
Are you willing to participate?
01 yes
02 no
Prior to the start of the group discussion, you will receive an information sheet with such information as sponsorship of the study and contacts for more information. If after we hang up, you have a question about this group discussion or decide you can’t participate, please contact me at ________________.
Name_________________________________________________________________
Address________________________________________________________________
City/State/Zip___________________________________________________________
Day Number_________________________Night Number_____________________
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | wernerk |
File Modified | 0000-00-00 |
File Created | 2021-01-25 |