Attachment C
Participant
Screener
Form Approved
OMB No. 0920-0572
Exp. Date: 3/31/2018
Public
Reporting burden of this collection
of information is estimated at 5 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).
Screening
Script and Questionnaire
Hello,
my name is __________, and I'm with <Focus Pointe>,
a research organization that is working with researchers at Battelle
and the Centers for Disease Control and Prevention or CDC. We’re
working with CDC to gather feedback on the My Mobility brochure and
to get ideas on how to distribute it. The tool is designed to help
people ages 60 or older protect their ability to get places they need
to go as they age. May I please speak to [NAME]?
Yes. (REPEAT INTRO IF NECESSARY AND PROCEED)
No Answer. (Leave a message as appropriate and follow-up later)
Hello [NAME] We’re looking for people to participate in a 2 hour focus group in ___MONTH_______of YEAR. If you are eligible to participate, you may take part in a focus group discussion with 4-6 people.
If you are interested, I will ask you a few questions to determine if you are eligible for the project. Your participation is completely voluntary, and all the information you provide will be kept private and secure. If you do not wish to provide this information, you are free to stop these questions at any time.
|
_______ |
If not between 60-74 (terminate) |
|
☐ Very good ☐ Good ☐ Fair (terminate) ☐ Poor (terminate) |
|
|
☐ Yes (terminate) |
☐ No (continue) |
|
☐ Yes (go to question #5) |
☐ No (record as Non-internet, go to question #5) |
|
☐ Several times a day ☐ About once a day
☐ 3-5 days a week ☐ 1-2 days a week ☐ Every few weeks (record as Internet User)
|
☐ Less often ☐ Never ☐ Don’t know/refused
(record as Non-internet) |
Based on your responses so far, I would like to invite you to participate in this project. This project will require a 2 hour appointment at one of Battelle’s research offices. During the appointment, you and 4-5 other people will participate in a group discussion. You will receive $75 in cash for your participation.
|
☐ Yes (continue) |
☐ No (terminate) |
|
☐ Yes (continue) |
☐ No (terminate) |
|
☐ Yes (continue) |
☐ No (terminate) |
(Discuss available times, and schedule as appropriate) |
___________________________ Date/Time Visit 1
___________________________ Date/Time Visit 2
___________________________ Date/Time Visit 3 |
|
(Verify Personal/Contact information, update as needed) |
Name
Phone
Confirm
address (for mailing letter and advance copy of MPT) |
|
(Record the following items for tracking purposes)
|
Date of Birth
Now I’d like to ask you some general questions about your background.
☐ Male ☐ Female
RECORD RESPONSE:
5. Do you wear eyeglasses, contacts lenses, or any kind of corrective eyewear?
☐ Yes ☐ No 6. Have you been diagnosed as colorblind or color deficient? ☐ Yes ☐ No |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 2021-01-21 |