Rapid Message Testing with Consumer Panel-Caregiver Tipsheet

FDA RAPID – MESSAGE #2

Caregiver Factsheet

Recruiting Screener

Introduction

The U.S. Food and Drug Administration, or FDA, hired Westat to help them get opinions about health information. Research Now is helping Westat and FDA find people who may be interested in being interviewed about health information. To make sure you are a good fit for the interview, please take about 3 minutes to answer the questions below.

1. Do you currently help an ill, disabled, or elderly adult manage their medications, medical devices, medical appointments, or other medical needs?

Yes

No  INELIGIBLE

2. Whose medical needs do you help manage? If you help more than one adult, select the person with the most medical needs.

Child 18 years or older

Spouse

Partner

Parent

Mother-in-law or father-in-law

Grandparent

Brother or sister

Friend

Other (please specify this person’s relationship to you)

3. What is this person’s main health problem or illness?

Chronic health condition like diabetes, or heart, kidney or lung disease

Cancer

Stroke

Memory problems, including Alzheimer’s or dementia

Congenital condition like cerebral palsy, autism, or Down’s syndrome

HIV/AIDS

Depression or other mental illness

Injury or short-term illness

Pain, mobility problems, or arthritis

Old age

Other (please specify the main health problem or illness)

Don’t know

4 How often do you help manage this person’s medical needs?

Just about every day

A few times a week

About once a week

About every other week

About once a month

Less than once a month  INELIGIBLE

5 How long have you been helping manage this person’s medical needs?

Less than 6 months

6 months to less than 1 year

1 year to less than 3 years

3 years to less than 5 years

5 years or more

6. Do you live in the same home as this person?

Yes

No

7. Do you work outside of the home?

Yes

No

8. What is your gender?

Female

Male  INELIGIBLE

9. What is your age?

Under 18  INELIGIBLE

18 to 34

35 to 49

50 to 64

65 or older

10. What is the highest grade or level of education you have completed?

Less than High School

High School Diploma or GED

Some College, including Associate’s Degree

Bachelor’s Degree (for example: BA, BS)

Graduate or Professional Degree INELIGIBLE

11. Are you of Hispanic, Latino, or Spanish origin?

YES

NO

12. What is your race? Please select one or more.

White

Black or African-American

American Indian or Alaska Native

Asian

Native Hawaiian or other Pacific Islander

Request for Contact Information

Thank you for answering the questions. Based on your answers, you may be chosen for an interview. If you are chosen for the interview and you finish it, you will get $35 E-Rewards Currency. At the start of the interview, the interviewer will ask if it’s okay to audio record it. This helps Westat to make sure they hear everything you say correctly. If you are chosen for an interview, you will get a package in the mail. Make sure to have the package with you during the interview. Is it okay with you for Research Now to share your contact information with Westat?

YES

NO  INELIGIBLE

Thank and Terminate

We’re sorry, you are not a good fit for an interview at this time. Thank you for taking the time to answer the questions.

Contact Information

In the space below, please give us the best information to contact you by phone, email, and regular mail. Please know that Research Now and Westat will not share your information with anyone else.

Contact Information

Name ______________________________________________________________________

Address 1 ___________________________________________________________________

Address 2 ___________________________________________________________________

City, State, ZIP _______________________________________________________________

Phone Number _______________________________________________________________

Email Address________________________________________________________________

Available Times

Someone from Westat will call or email in the next 1-2 days to schedule an interview with you. Please mark the times you can be reached by phone in the next 1-2 days.

9 a.m. to Noon

Noon to 2 p.m.

2 p.m. to 5 p.m.

5 p.m. to 7 p.m.

7 p.m. to 9 p.m.

Technology Preferences

The Westat interviewer would like to be able to show you information on her computer screen during the interview. Westat will send directions for how to view the interviewer’s screen. Which app do you prefer for screen sharing?

Skype

Google Hangouts

Zoom

WebEx

I am not able to use any of these, please just call me

Closing

Thank you for your answers to these questions. If you are chosen for an interview, someone from Westat will contact you within the next 1-2 days.