MCH Survey Eligibility and Consent Script_SAMOAN

SAMOAN

MCH Jurisdictional Survey Eligibility and Consent Scripts

Eligibility

Talofa o lo’u igoa o _________. O a’u o se tasi mai le vaega o le su’esu’ega o loo faia, ina ia faatauteleina le malamalama i le soifua maloloina o tina ma fanau i [Amerika Samoa/Setete o le Fetorale i Maikolenisia/Atumotu o Marshall/Atumotu o le Northern Mariana/Palau]. O lou auai I lenei su’esu’ega e aofia ai le taliina o ni fesili e tusa male soifua maloloina o oe ma lau fanau.

1. Ua filifilia lou fale e aunoa ma se faapogai. Pe mafai ona ou fesili atu ni nai fesili ina ia iloa ai pe ete agavaa e faisao i lenei su’esu’ega?

1 IOE [GO TO 2]
2 LEAI [Thank individual for their time and leave]

99. ELE TALI INA [Thank individual for their time and leave]

2. Pe e 18 ou tasaga pe matua atu?

1 IOE [GO TO 3]
2 LEAI [Thank individual for their time and leave]

99 Musu e tali fesili [Thank individual for their time and leave]

3. Poo oe o le tina o se tamaitiiti e i lalo ifo ole masina le matua e oo atu i le 17 tausaga o nonofo faatasi ma oe?

1 IOE [Go to informed consent]
2 LEAI [Thank individual for their time and leave]

99 ELE TALI INA

4. E iai se tamaitai e 18 tausaga le matua i le tou fale , po’o se tina po’o se tamaitai o vaaia tamaiti mai le pepe agai i le matua e 17 tausaga e mafai ona ou talanoa atu iai?

1 Ioe [Go to beginning]
2 Ioe ae e le’o avanoa [Go to 5]

3 Leai [Thank individual for their time and leave]

99 Musu e tali fesili [Thank individual for their time and leave

5. O le a se taimi lelei ou te toe sau ai ma te talanoa ?

1 IOE [Write down time]
2 LEAI [Thank individual for their time and leave]

99 ELE TALI INA [Thank individual for their time and leave]

Consent

[INFORMED CONSENT OBTAINED AFTER DETERMINING ELIGIBLE CHILD(REN) IN THE HOUSEHOLD]

Ua matou faatinoina lenei sailiiliga e malamalama ai faatatau i le soifua maloloina o tina
ma fanau. lenei sailiiliga o se vaega o le Polokalama o le Title V MCH Block Grant, faatupeina e le Matagaluega o Punaoa o Soifua Maloloina ma Auaunaga (HRSA)

O au tali i fesili o lenei sailiiliga e fesoasoani lea i Polokalama mo Soifua Maloloina o Tina ma Fanau ia malamalama atili ai i soifua maloloina o tina ma fanau i le tou aai ma o le a faaaoga e tapena ma tiliva ai fesoasoani ma auaunaga mo aiga. Pe a ma le 50 minute e faatino ai le sailiiliga ma o fesili e faatatau i lou soifua maloloina ma le soifua maloloina o le tamaitiiti.

E lē faamalosia oe e fai sao i le su’esu’ega. E mafai ona e ioe e fai sao i le su’esu’ega i letaimi nei ma toe sui lou mafaufau mulimuliane. E lē faamalosia oe e tali soo se fesili e te lē mana’o e tali. I ne’i iai ni fesili i pa’o papa i le faafofoga, ae poo a ni lagona, e le iai ni lamatiaga ia oe po’o lou aiga pe a e filifili e te auai.

Afai ua e finagalo e te auai, e maua sina meaalofa e faafetaia ai lou taimi, ae peitai e le maua se fesoasoani tuusa’o i lou tali mai i fesili o le sailiiliga.

O tali e tuuina mai o le a malu puipuia tumaoti. Pau tagata e faatagaina e vaai i au tali ua na’o e o lo’o galulue i lenei sailiiliga ma e o lo’o maitauina le sa’o o le faatinoga o le sailiiliga. O le a le tuuina i luga lou igoa i le sailiiliga faatasi ma au tali. E matou te faaaogaina se numera e faamauina ai au tali, ae le o lou igoa.

O le a lē fesiligia e le su’esu’ega le faileagaina o le tamaitiiti poo le tuulafoaia o ia. Afai e te iloa le faileagaina poo le tuulafoaia o se tamaitiiti, e tatau ona matou ripotia i ē pule o feagai ma tulaga faapea.

Faamolemole faafesootai X i le (XXX) XXX-XXXX poo le JMCH@norc.org mo fesili, faitioaga poo popolega e tusa ai ma lenei su’esu’ega. Afai e iai sau fesili poo ni popolega e tusa ai ma ou aiā tatau i le avea ai ma se sui mo lenei suesuega, faamolemole faafesoota’i le NORC Institutional Review Board Manager e ala i le numera o le telefoni e lē totogia (866) 309-0542.

O le a tuu le pepa lenei ia oe e fai ma faamaumauga o faamatalaga ua uma ona ou talanoa atu ai. [Provide the paper copy of the informed consent language]

1. E iai ni fesili?

Ioe [Answer questions, then go to B]
Leai [Go to B]

Musu e tali fesili [Thank individual for their time and leave]

2. E te malie e tali mai i fesili o le sailiiliga?

Ioe [Thank individual and begin the questionnaire]
Leai [Thank individual for their time and leave]

Musu e tali fesili [Thank individual for their time and leave]