HMTS Radiation Focus Group and Emergencies Infographics

CDC and ATSDR Health Message Testing System

Att C-1 ORIG Screenng Instrmnt Word 20130912

HMTS Radiation Focus Group and Emergencies Infographics

OMB: 0920-0572

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ATTACHMENT C-1: Screening Instrument

CDC Message Testing: Radiation Emergencies Infographics

(Online Survey)

Form Approved
OMB No. 0920-0572
Exp. 02/28/2015


LEVEL 1

  1. 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

[RECRUIT A MIX]


  1. 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.)

05 An employee for any of the following:

  • 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

[IF YES TO ANY, THANK AND TERMINATE]




Public reporting burden of this collection of information is estimated to average 3 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).

LEVEL 2

  1. Gender (A.1.a)

01 Male

  1. Female

[RECRUIT ABOUT A 50/50 MIX]


  1. [FOR WOMEN] Have you been pregnant in the past year? (A.46.a)

01 YES -> SHOW PREGNANCY INFOGRAPHIC

02 NO -> DO NOT SHOW PREGNANCY INFOGRAPHIC


DEMOGRAPHICS

  1. What is the highest level of education you have completed? (A.4.a)


01 Grade school

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

[RECRUIT A MIX]



  1. Are you Hispanic, Latino/a,or Spanish Origin?
    (One or more categories may be selected)

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


  1. Please indicate your race or ethnic background.


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]


  1. In what state, city, and zip code do you currently live? ENTER FIVE DIGIT ZIP CODE. (A.9.a)




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Authorwernerk
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