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pdf[SURVEY PREVIEW MODE] Attachment C-2 Screening Instrument
Attachment C-2 Screening Instrument
U. S. Department of Health and Human Services
CDC Study
Information for Participants
Purpose of this survey
You are being asked to participate in a survey sponsored by the Centers for Disease Control and
Prevention (CDC), with the assistance of The Oak Ridge Institute for Science and Education. In the
survey, you will be asked your opinions and practices regarding some information about [subject matter]
that might be provided to other people like you. Your answers can help efforts to provide accurate, helpful
information to the public.
Please remember that:
You choose to participate. You are not required to answer the questions. This session should last about
15 minutes. You will receive $3 as a token of appreciation for participating in the survey. You are free to
stop answering questions at any time without penalty.
Risks
The risks you take by taking part in the discussion are the same as you encounter in daily life.
Benefits
You may be better informed about a public health issue. You may have a sense of satisfaction from
contributing. Your comments may help improve the information the public receives.
We will keep the information you give us private to the extent allowed by law. Your name will not be used
in the final report. No statement you make will be linked to you by name. Only members of the research
staff will be allowed to look at the records. When we present this study or publish its results, your name or
other facts that point to you will not show or be used.
Persons to Contact
If you have questions about this session, or taking part in it, you may call: Dr. Armin Ansari (770-4883800) at the Centers for Disease Control and Prevention, Atlanta, GA.
If you need more information about your rights as a study participant, you may contact: Oak Ridge SiteWide Institutional Review Board, Oak Ridge Institute for Science and Education, Oak Ridge, TN 865576-1725.
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[SURVEY PREVIEW MODE] Attachment C-2 Screening Instrument
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Attachment C-2 Screening Instrument
Form Approved
OMB No. 0920-0572
Exp. 02/28/2015
*1. In which of the following categories does your age fall?
Under 18 years of age
18-24 years of age
25-34 years of age
35-44 years of age
45-54 years of age
55-64 years of age
65-74 years of age
08 75 years of age or older
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).
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Attachment C-2 Survey Questions
*2. Do you, or does any member of your household or immediate family work
For a market research company
For an advertising agency or public relations firm
In the media (TV/radio/newspapers/magazines)
As a healthcare professional (doctor, nurse, pharmacist, dietician, etc.)
As an employee of the U.S. Department of Health and Human Services
As an employee of a state or local health department
As an employee of the Department of Homeland Security
As an employee of a state or local emergency management agency
As a nuclear power plant employee, Radiation Safety Officer, health physicist or other radiation-related
occupation
None of the above
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*3. What is the highest level of education you have completed?
Grade school
Less than high school graduate/some high school
High school graduate or completed GED
Some college or technical school
Received four-year college degree
Some post graduate studies
Received advanced degree
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*4. Please indicate your race or ethnic background. Are you?
Hispanic or Latino
Non-Hispanic or Latino
*5. What is your race? Mark one or more.
White/Caucasian
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Asian
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*6. In what state, city, and zip code do you currently live? ENTER FIVE DIGIT ZIP CODE
State
City
Zip
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*7. What is your gender?
Female
Male
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*8. Have you been pregnant in the past year?
Yes
No
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| File Type | application/pdf |
| File Modified | 2013-08-19 |
| File Created | 2013-08-19 |