Professional - Screener

Form Approved

OMB No. 0920-0572

Expiration Date 03/31/2018

Submission under

0920-0572 Health Message Testing System

Attachment 12: Professional In-depth Interview/Focus Group/Intercept Interview Screener

Public reporting burden of this collection of information is estimated to average 2 hours 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 NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0572)

Professional Individual Interview and Focus Group Screening Instrument

Introduction

Hello, my name is _______________ and I’m from (name of company). We are calling on behalf of RTI International, a non-profit research organization, and the Centers for Disease Control and Prevention.

We are not selling any product. We are calling to invite men/women who work with people with or at risk for HIV/AIDS to join in interviews as part of a research study about HIV. Your opinions are important to us and will contribute to the CDC’s fight against HIV/AIDS.

If you are eligible and choose to participate in the interview, you will receive $100 as a token of our appreciation for participating in this important study.

To see if you are eligible for this study, we need to ask you some personal questions about yourself and your occupation. It is your choice to answer these questions. Your answers will be kept private. You can refuse to answer a question or stop at any time.

All of your comments will be kept private. If you are not eligible and/or choose not to be part of the study, all responses you give me today will be destroyed and you will not be contacted again.

My questions will only take a few minutes. May I ask you the questions now?

Yes..................1 Continue

No....................2 End

Procedures for Recording and Limiting Information

Only record information for the questions in the screener. If an informant reveals additional personal information, thank them for being helpful, but guide them back to the screener questions- “That is interesting to learn, but can I know ask you about...”

1. Have you ever participated in focus group or interview session before?

Yes	1
No	2	[SKIP TO Q3]

2. What was/were the topics discussed?

[IF PARTICPATED IN A FOCUS GROUP OR INTERVIEWABOUT HIV/AIDS IN THE PAST 6 MONTHS, THANK AND END]

3. What was your sex assigned at birth?

₁ Male

₂ Female

₂ Intersex

₈ Don’t know [INELIGIBLE]

₉ Prefer not to answer [INELIGIBLE]

4. Do you consider yourself to be male, female, or transgender? (check only one)

₁ Male

₂ Female

₃ Transgender man (or Transmale or Transman)

₄ Transgender woman (or Transfemale or Transwoman)

₈ Don’t know [INELIGIBLE]

₉ Prefer not to answer [INELIGIBLE]

5. May I ask if your age is in any of the following categories? Are you... [READ LIST]

Under 18 years old	1	[THANK & END]
18 – 24	2
25 – 34	3
35 – 44	4
45 – 54	5
55 – 64 …………………………..……………...	6
Refused	7

6. Are you Hispanic or Latino/a

a. ____No

b. ____Yes

c. Prefer not to answer

7. What is your race? (One or more categories may be selected – recruit mix)

a. ____White

b. ____Black or African American

c. ____American Indian or Alaska Native

d. ____Asian

e. ____Native Hawaiian or Other Pacific Islander

f. Other race [specify:___________________]

g. Prefer not to answer

8. In what country or territory were you born?

₁ United States

₂ Puerto Rico

₃ Mexico

₄ Cuba

₅ Other [Specify: ]

₉ Prefer not to answer

9. How many years have you been living in the United States?

[If less than one year, put 0 in the space. Round to whole years]

_____________years

10. What language are you most comfortable using with your family and friends?

₁ English

₂ Spanish

₃ English and Spanish equally

₄ Other [Specify: ]

₉ Prefer not to answer

11. What is your current relationship status? Are you…?

Single	1
Married to a man	2
Married to a woman	3
In a relationship with a man	4
In a relationship with a woman	5
Divorced or Widowed	6
Refused	8

12. Which best describes your total personal income during the past year?

₁ Less than $20,000

₂ $20,001 to $30,000

₃ $30,001 to $40,000

₄ $40,001 to $50,000

₅ $50,001 or more

₉ Prefer not to answer

13. What is the highest grade or year of school you finished?

₁ Never attended school or only attended kindergarten

₂ Grades 1 through 8 (elementary)

₃ Grades 9 through 11 (some high school)

₄ Grade 12 or GED (high school graduate)

₅ College 1 year to 3 years (some college or technical school)

₆ College 4 years or more (college graduate)

₉ Prefer not to answer

14. What is your occupation?
[READ LIST IF NECESSARY – RECRUIT MIX]

Health Teacher	1
Educator (Principal, School Board)	2
Social Worker	3
Public Health Worker	4
Other:_____________	5
Refused	6

15. In your occupation, do you work with populations that have, or are at risk for HIV/AIDS?

Yes	1
No	2

15a. If yes, in what capacity do you work with populations that have, or are at risk for HIV/AIDS? ___________________________________

16. How long have you worked in your current position?

Less than 6 months	1
Six months to 1 year	2
One to three years	3
More than three years	4

Invitation:

As I mentioned earlier, we are talking to professional men/women about HIV/AIDS and we would like to include your opinions. We would like to invite you to take part in an informal interview/focus group session that will last about 1 hour. You will not be asked to buy anything. You will you be contacted at a later date to remind you of the interview. Any information that you provide to us will be kept private. We’re simply interested in your opinions.

17. For participating in the interview/focus group, you will receive $100 as a token of our appreciation. Will you be able to join us for an interview/focus group?

Yes	1	[Skip TO Q19]
No (Refuse to participate)	2	[THANK AND END]

18. Closing for Ineligible Participants:

Thank you for answering all of my questions. You are not eligible to be in this study. There are many possible reasons why people are not eligible for the study. These reasons were decided earlier by the researchers. We value your interest in this research study. Thank you for being willing to help us.

19. [IF “YES” TO EITHER INVITATION, READ THE FOLLOWING STATEMENTS…]

“We will be audiotaping the interview and some project staff from CDC may be observing the interview. We may also use a live video or audio stream so project staff from CDC can observe from a computer in another location.” In order to participate in the interview, you must agree to being audiotaped and allowing staff from the CDC to observe. As I said, if you choose to attend, whatever you say will be kept private. We will never link your name with any comment you make in the interview in any report that we write.”

“If you need to wear glasses either for reading or watching TV, please bring them with you to the interview.”

“Also, we need to let you know that there will not be any childcare provided at the facility, so please make the appropriate childcare arrangements if you have children.”

In order for us to send you a reminder letter/email with directions to the interview and to call to remind you of your appointment time, I need to ask for your contact information. We will destroy this information after the interview is over.

Participant Information

Interviewer: ________

Date: ________

Letter sent: ________

Reconfirmation: ________

Call

NAME: ______________________________________________________

ADDRESS: ______________________________________________________

CITY: ______________________________________________________

ZIP CODE: ______________________________________________________

Phone : Day ___________________ Evening ___________________

EMAIL _______________________________________________________

What is the best time to reach you? What is the best telephone number to reach you at that time? If you do not answer, may we leave a private message at that number?

BEST TIME TO BE REACHED: ________________________________________

BEST PHONE NUMBER: ________________________________________

Is there another time and number we can try if we miss you?

ALTERNATE PHONE NUMBER:

Your participation in this study is very important. If for some reason you will not be able to attend, please let us know right away. You can call us anytime at [insert phone number], and if we are not here, please leave a message. You can also call if you have any questions. Thank you.