Screener and Focus Group Invitation

Form Approved

OMB Control No.: 0920-0572

Expiration date: 08/31/2021

Telephone Recruitment Screener for Potential Focus Group Participants for Testing Health Communication Messages to Promote Hepatitis C Testing among U.S. Adults

Hello. My name is _______ and I’m calling from [CONSULTING COMPANY] an independent marketing firm.

We are working on a project for the Centers for Disease Control and Prevention, CDC, part of the nation’s public health service. CDC is the sponsor of this project collecting qualitative feedback from men and women on some educational materials on a specific health topic.

CDC is not interested in any personal details. We would like to ask you a few questions to see if you qualify for the small group discussions and to ensure we are recruiting a diverse mix of people; but this information will not be shared with anyone. All of your responses will be kept private.

Are you female, male or do you identify in another way?

Female	
Male	
Prefer to self-identify: Write in: _________________	

2. How would you describe your racial or ethnic background?

[RECORD OPEN-ENDED RESPONSE; READ LIST AS NEEDED BUT DO NOT READ “PREFERRED NOT TO ANSWER/DON’T KNOW/NOT SURE”- THOSE RESPONSES ARE ONLY THERE AS BACKUP OPTIONS IF RESPONDENTS DO NOT RESPOND WITH THE OTHER PREFERRED/SPECIFIC RESPONSES LISTED BELOW]

Do you consider yourself Hispanic or Latino/a?

Yes	
No	
Preferred not to answer	

What is your race?

(READ THE FIRST 5 OPTIONS LISTED BELOW AND TELL THE RESPONDENTS THEY CAN SELECT ONE OR MORE OF THE FOLLOWING; DO NOT READ “PREFERRED NOT TO ANSWER/DON’T KNOW/NOT SURE”- THOSE RESPONSES ARE ONLY BACKUP OPTIONS)

White or Caucasian	
Black or African-American	
American Indian or Alaska Native	
Native Hawaiian or Other Pacific Islands	
Asian	
Don’t Know/Not Sure	
Preferred not to answer	

3. What year were you born? [RECORD ON LINE BELOW] MUST BE BORN BETWEEN 1959 AND 1998 (AGE 21-60)

4. Do you currently have a doctor or health professional that you see regularly for routine check-ups or annual exams and other preventative health issues?

Yes	
No	

5. When was the last time you saw a doctor or health care provider for a physical or routine exam? Was it…?

Within the last 6 months	
Within the last year	
Within the last 2 years	
More than 2 years ago	

6. In the last year have you ever gotten a blood test specifically for…?

Diabetes	
Cholesterol	
Hepatitis	
STD	
HIV	

6. Have you ever been told by a doctor or other health professional that you have or have had any of the following…?

Diabetes	
Heart attack, also known as an MI or myocardial infarction	
Hepatitis	
Cancer	
HIV or AIDS	

6. Have you or anyone in your immediate family or household ever had liver disease?

Yes	
No	

6. Have any of your direct family members ever been diagnosed with any of the following diseases…?

Diabetes	
Heart disease	
Liver disease	
Hepatitis	
HIV or AIDS	

6. What is the highest grade of school you completed?

Less than high school	
Some high school	
High school graduate	
Some college	
College graduate	
Post-graduate degree	

6. We want to be sure we represent a broad range of people in this market research study. Please stop me when I read the range that includes your total annual household income.

Less than or equal to $9,999	
$10,000 – $14,999	
$15,000 – $24,999	
$25,000 – $34,999	
$35,000 – $49,999	
$50,000 – $64,999	
$65,000 – $74,999	
$75,000 – $99,999	
$100,000 or more	
Refused (OK to continue if otherwise qualifies)	

15. Have you participated in a focus group, intercept interview, telephone survey, and/or online survey in which you were asked your opinions regarding a product, a service, or advertising within the past six months?

No	
Yes	

16. Do you, or does any member of your household or immediate family work for:

a market research company	
an advertising agency or public relations firm	
the media (TV/radio/newspapers/magazines)	
as a healthcare professional (doctor, nurse, pharmacist, dietician, etc.)	

INVITATION TO PARTICIPATE

Thank you for answering my questions. We would like to invite you to participate in a focus group discussion. The discussion will last approximately two hours.

This project is for feedback purposes only. All of your comments during the group will be de-identified and only reported in the aggregate. The discussion will be audio recorded to help us make sure we capture everyone’s feedback.

You will receive [$75] for your participation, which will be provided to you after your participation in the group.

Is this something you are interested in and comfortable with?

Yes	
No		THANK AND TERMINATE

I’m going to read you the times and dates we have open. Please let me know which ones works best with your schedule.

How would you like us to confirm this meeting with you?

 Telephone: ( __ ) __________

 Email: @

If you have any questions, please call the project recruitment coordinator for this project at INSERT NAME OF RECRUITMENT COORDINATOR

SEPARATE THIS CONTACT SHEET FROM THE RESET OF THE SCREENER

AND SHRED AT THE END OF THE STUDY

Public reporting burden of this collection of information is estimated to average 10 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 NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-0572