English Language Screening Instrument

Form Approved

OMB No. 0920-1154

Exp. Date 01/31/2020

Attachment 2a:

CDC’s Inside Knowledge Campaign, 2018 Focus Groups ENGLISH SCREENING INSTRUMENT

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, 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, MS D-74, Atlanta, GA 30329, ATTN: PRA (0920-1154).

Screening Instrument: Women aged 35-65 years

GROUP DATE/TIME:_____________________________________________________________________

______Ages 35-49

______Ages 50-65

Name:_______________________________________________________________________________________

Phone # +/or e-mail address for confirmation: ______________________________________

________________________________________________________________________________________________

Address: ____________________________________________________________________________________

City, State: _____________________________________ZIP Code:

Hello, my name is . I’m with , a local public opinion research company. Today, we are working on a study to learn more about what women have heard about certain types of cancer. The research is sponsored by the Centers for Disease Control and Prevention, or CDC – part of the public health service – and will be used to plan new health education materials. I want to assure you that this is strictly about your ideas and opinions. There are no medical tests or procedures, or medications. And none of the ideas or opinions you provide will be used afterwards to try to sell anything. Some of the women I talk with may be invited to participate in another part of the opinion study that will last for about 2 hours, for which they will receive a token of appreciation. May I ask you a few questions today?

NOTE: Participants must be able to understand English well and speak English clearly enough for audiotapes to be transcribed -- please listen carefully during recruitment calls to make sure that anyone recruited can understand English and also speak clearly and loudly enough to participate well in English.

1. Are you currently employed? [CONTINUE for all -- Recruit a mix]

1. No

2. Yes, part time

3. Yes, full time

(If yes...) What type of work do you do? _________________________________________

(Information only – try to get type of business (e.g., pet sitting, deli, car sales) AND type of position (e.g., owner, sales, office manager, etc.)

2. Have you or your spouse/partner ever worked or volunteered for any of the following types of organizations?

1. Doctor’s office, hospital, clinic, pharmaceutical or drug company

2. Health department or community health agency

3. Marketing research, advertising, or public relations agency or

Department

4. Centers for Disease Control and Prevention (“C-D-C”) or the National

Institutes of Health (“N-I-H”)

5. An organization that focuses on cancer, such as the American Cancer

Society or another cancer-related organization

If yes to any:

Please find out what type(s) of paid or volunteer position and whether position was held by respondent and/or spouse or partner. _______________________________________________________________

[TERMINATE if prospective participant or spouse/partner is obviously a health professional such as doctor or nurse. Otherwise, continue screening but check with client before recruiting if not sure whether respondent or spouse/partner is in a health profession.]

3. For this study, I need to ask your age [IMPORTANT: please fill in exact age]: ________

For each market, recruit two groups of women ages 35-49 and two groups 50-65.

Important to represent the full age range – e.g., for 43-49, must have some women at the upper end of the range; for 57-65, must have some women in their 60s and so forth for all ranges.

FOR GROUPS WITH WOMEN AGES 35-49:

1. Under 35 years old [TERMINATE]

2. 35-42 [Recruit at least 6]

3. 43-49 [Recruit at least 6]

4. 50+ [TERMINATE]

FOR GROUPS WITH WOMEN AGES 50-65:

1. Under 50 years old [TERMINATE]

2. 51-56 [Recruit at least 6]

3. 57-65 [Recruit at least 6]

4. Age 66+ [TERMINATE]

4a. Do you consider yourself to be …? [Read responses 1 & 2]

1. Hispanic or Latino

2. Not Hispanic or Latino

3. Don’t Know/Not Sure (DO NOT READ)

4. Refused (DO NOT READ) ............ Thank and terminate

4b. Do you consider yourself to be…? [Read responses 1-5 and allow respondent to select one or more]

1. White/Caucasian

2. Black or African-American

3. American Indian or Alaska Native

4. Native Hawaiian or Other Pacific Islander

5. Asian

6. Don’t Know/Not Sure (DO NOT READ)

7. Refused (DO NOT READ) …… Thank and terminate

5. Do you have any kind of health insurance to pay for routine health care? [Information only]

1. Yes

2. No

3. Not sure

6. Have you ever had a Pap test? You may have heard it called a Pap smear. It’s the same thing. [Information only]

1. Yes: Approximately when was the last time? __________

2. No

3. Not sure

6a. Have you ever been told that you had an abnormal Pap result?

[Information only]

1. Yes 2. No 3. Not sure

7. Have you ever been told that you have fibroids? [Information only]

1. Yes 2. No 3. Not sure

8a. Have you ever been told that you have HPV (the Human papillomavirus)?

[Information only]

1. Yes 2. No 3. Not sure

8b. Have you ever had an HPV test? If so, when was the last time? [Information only]

1. Yes Approximately when was the last time? ______________________

2. No

3. Not sure

9. Have you had a hysterectomy?

1. Yes [TERMINATE]

2. No

3. Not sure [TERMINATE]

10. Have you ever been told by a doctor that you have any type of cancer?

1. No [Continue]

2. Yes: What type(s)? ______________________________________

[TERMINATE FOR ANY RESPONSE OTHER THAN “skin cancer”, “basal cell” or “squamous cell”. ]

If BREAST CANCER, ask when and status. Terminate, but save all terminates for breast cancer.

11. Have any of your close female relatives [such as a sister, mother, or aunt] or any close female friends ever been diagnosed with any cancer?

1. No [Continue; Skip to Q12]

2. Not sure [Continue; Skip to Q12]

3. Yes If yes, ask:

a. Female friend or relative? (ID which relative; e.g., mom aunt, etc.)	b. Type of cancer	c. Approximately when (year)	d. How is she doing? (ok/good, remission, passed away)

IF Column B ONLY has one or more of the following, SKIP to Q12:

Skin cancer, basal cell, squamous cell

IF Column B has one of the following gynecologic cancers...

Cervical

Endometrial

Ovarian

Fallopian Tube

Uterine

Vaginal or vulvar

Prefer none, but if necessary to fill group, OK to recruit max of 1-2 IF:

Column A has no more than 3 relative/friends with any cancers other than skin AND

Column C has no dates later than 2014

If not, Terminate.

For other prospects whose Column B has only other cancers not on the gyn cancer list, OK to recruit 1-2 IF:

Column A has no more than 3 relatives/friends AND

Column C has no dates later than 2014

Save ALL terminates for Q11.

12. What is the highest grade of school you completed? [Read list]

Recruit at least 2 with no more than high school/GED education:

1. Less than high school [OK if none]

2. High school or GED

Recruit at least 5 with some college or 2 year degree:

3. Two year college or technical school

4. More than two years of college, but less than 4

Recruit at least 5 per group with 4-year college degree or more:

5. 4-year college degree

6. Post-graduate degree [No more than 1-2 per group. Completely OK if none.]

13. Please stop me when I read the range that includes your total household income each year. This information is not going to be shared with anyone.

[Note: It is important to recruit a mix of low, middle, upper middle income – income ranges can be adjusted as needed for each city/facility.]

1. Less than or equal to $25,000 per year

2. More than $25,000, less than $40,000

3. More than $40,000 less than $65,000

4. More than $65,000, less than $100,000

5. More than $100,000 *

6. prefer not to answer *

* No more than 4 total who answer 5 or 6.

14. For statistical purposes, what is your marital status? [Information only]

[Do not read response options.]

1. Never married

2. Married

3. Living with partner

4. Separated

5. Divorced

6. Widowed

7. Other

15. When, if ever, was the last time you participated in any type of a research study, such as a focus group?

1. Have never participated [Continue]

2. Within the last 12 months: What was the topic? _____________________________

If related to cancer, terminate. Prefer not to take anyone with health-related focus group experience in the last year if possible. Save all terminates.

1. Have you participated in a focus group related to cancer in the last 5 years?

If yes.....

2. What kind of cancer? [Do not read] TERMINATE IF SHE SAYS:

Cervical

Endometrial

Ovarian

Fallopian Tube

Uterine

Vaginal or vulvar

Gynecologic cancer

COLON [To try to exclude people who participated in 2015 SFL groups)

Breast is OK.

3. NO [Continue]

16. READING COMFORT:

I have one more question. Part of our study may involve some reading. Some people have vision or reading difficulties, so they may prefer to be considered for other studies we do instead. Are you comfortable with brief reading tasks or would you prefer to be contacted for another study that does not involve reading?

____Reading is OK.

17. INVITATION:

The project I am working on includes several small groups with about 9 women who will meet once for about two hours to talk informally about what they have heard about certain types of cancer. The discussion will be at our office, which is easy to get to. You do not need any special skills to participate, although there will be some reading involved.

You will receive a token of appreciation of about $75 for your participation.   

We would like to invite you to be in a group on... [See schedule]

Are you available?

1. No [Thank and end call.] 2. Yes

Great…I will send you a confirmation letter with directions.

Please note that there is a possibility that some women who are invited may not be needed, but we won’t know that until everyone arrives. If this happens, everyone who arrives on time will receive the token of appreciation, even if you are not asked to stay. We thank everyone for understanding this possibility.

CONFIRMATION LETTER AND CALL SHOULD REMIND WOMEN TO BRING READING GLASSES.

11