0920-18JC Women's Health Need STUDY_Screener

Public reporting burden of this collection of information is estimated to average 1 minute 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-xxxx).

SECTION A. SCREENER

1. Have you previously participated in the Women’s Health Needs Study (WHNS)?

Yes [END SURVEY]

No

2. Which of the following languages do you speak?

Amharic

Arabic

English

Somali

Swahili

Other, please specify:

3. Which language would you prefer to use for this interview? [INTERVIEWER NOTE: IF YOU DO NOT SPEAK THE LANGUAGE PREFERRED, MAKE NOTE AND END INTERVIEW].

4. In which country were you born?

Don’t Know

Prefer not to answer

<SKIP LOGIC: IF RESPONDENT MENTIONS EGYPT, ERITREA, KENYA, SOMALIA, or ETHIOPIA,,GUINEA, LIBERIA, NIGERIA, SIERRA LEONE or SUDAN. GO TO Q6>

5. Have you ever lived in any of the following countries?

Yes No Don’t Prefer not

Know to answer

Egypt

Eritrea

Kenya

Somalia

Ethiopia

Guinea

Liberia

Nigeria

Siera Leone

Sudan

6. In which country was your father born?

Don’t Know

Prefer not to answer

7. In which country was your mother born?

Don’t Know

Prefer not to answer

<SKIP LOGIC: IF RESPONDENT MENTIONS EGYPT, ERITREA, KENYA, SOMALIA, or or ETHIOPIA,,GUINEA, LIBERIA, NIGERIA, SIERRA LEONE or SUDAN. \ GO TO Q9>

8. Has your mother lived in any of the following countries?

Yes No Don’t Prefer not

Know to answer

Egypt

Eritrea

Kenya

Somalia

Ethiopia

Guinea

Liberia

Nigeria

Siera Leone

Sudan

9. How old are you?

• Under 18 years

• 18-24

• 25-29

• 30-34

• 35-39

• 40-49

• Over 49 years

• Prefer not to answer

E ligible: if between 18-49 years old, birth location or country lived if respondent or mother fits criteria from country list, and translation options are necessary and available, respondent is eligible. Review consent material and proceed to full interview if consent obtained.

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File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Pazol, Karen (CDC/ONDIEH/NCCDPHP)
File Modified	0000-00-00
File Created	2021-01-15