Form 2 HCP Recruitment Screener

OMB Control # XXXX-XXXX

Expiration Date XX/XX/202X

Public reporting burden for this collection of information is estimated to average 5 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 current 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 NIH, Project clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (XXXX-XXXX). Do not return the completed form to this address.

Federal COVID-19 Response

Audience Feedback Team for Quick and Ongoing Message, Materials, and Usability Testing – Healthcare Provider Recruitment Screener

The healthcare provider feedback team will reflect a mix of

gender, provider type, years in practice, state, and practice type.  

	Target Audience
	Healthcare providers who have treated COVID-19 positive patients
Participant Quantity	Recruit 20
Commitment	Up to 6 60-minute sessions over a 12-month period (no more than 12 total)

QUOTAS AND ELIGIBILITY

• Recruit 20 healthcare providers, including MDs, PAs, NPs, RNs, and clinical support staff who work directly with/treat COVID-19 positive patients and their families.  

• Recruit a mix of gender, provider type, years in practice, state, and practice type.  

RECRUITMENT SCREENER

April 2021

Introduction

Hello, my name is _______________ and I’m calling from _________________about an upcoming research project sponsored by the U.S. Federal COVID-19 Response Team.

We want to talk with healthcare providers who have treated COVID-19 positive patients about how we can better reach people with an important resource for information about available COVID-19 treatment clinical trials and treatment options.

We are interested in recruiting participants who are willing to participate in up to six qualitative virtual feedback sessions (online bulletin boards, focus groups, in-depth interviews, website usability testing activities [i.e., card sorts]) over a 12-month period. Each feedback session will take place virtually via Zoom, and last, on average, 60 minutes.

To maintain participants’ privacy, we will use first names only during the sessions and your name will not be used in any project materials. To thank you for your time, you will be given a monetary token of appreciation following each activity that you participate in. To see if you qualify to participate, we need to ask you a few questions. These questions will take less than 6 minutes.

Eligibility Questions

RECRUIT 20 TOTAL PARTICIPANTS.

*Confirm that the individual speaks English clearly.   _____ 

 

 What is your gender?

( ) Male

( ) Female

( ) Prefer to describe _______

RECRUIT A MIX OF GENDERS, AS POSSIBLE.

1. Which of the following best describes your profession: 

  (   ) Physician (e.g., MD, DO)  

(   ) Nurse (e.g., LPN, RN, NP, CRNA) 

(   ) Physician Assistant  

(   ) Allied health (PT, OT) 

(   ) Clinical support staff (CNA, PTA, OTA)

(   ) None of the above; THANK AND DISMISS 

 

RECRUIT A MIX OF PROFESSIONS AS POSSIBLE. 

 

2. Do you or have you worked with patients who are positive for COVID-19? 

(   ) Yes   

(   ) No; THANK AND DISMISS 

3. Which best describes your clinical setting? 

(   ) Hospital 

(   ) Primary care clinic 

(   ) Specialty clinic 

(   ) Community clinic 

(   ) Traveling position  

(   ) Other: Please describe  

RECRUIT A MIX AS POSSIBLE. 

 

4. In which state do you practice?  

 

     __________________________  

 

RECRUIT A MIX AS POSSIBLE. 

5. Which of the following best describes the type of area you work in?  

(   ) Urban (city) 

(   ) Suburban 

(   ) Rural 

(   ) Small city or town 

(   ) Reservation or Frontier (classify as rural) 

 RECRUIT A MIX AS POSSIBLE 

 

6. What is the closest major city to where you live?

Record:_________

RECRUIT A MIX OF DESIGNATED MARKET AREAS AS POSSIBLE.

7. Which of the following categories best describes your ethnic background? 

(     ) Not Hispanic or Latino 

(     ) Hispanic or Latino 

 RECRUIT A MIX AS POSSIBLE 

 

8. What is your race? (One or more categories may be selected)  

( ) American Indian or Alaska Native

( ) Asian

( ) Black or African American

( ) Native Hawaiian or Other Pacific Islander

( ) White

 RECRUIT A MIX AS POSSIBLE 

 

STRIVE TO RECRUIT A MIX OF RACES/ETHNICITIES (PREFERRED, BUT NOT NECESSARY).  

 

Do you have access to an internet-connected computer? We’re asking this question because we’ll be showing participants materials on occasion through a shared screen during the discussion, and participants will need a large enough screen to view the materials in their entirety and in detail.  

 

(   ) Yes 

(   ) No; THANK AND DISMISS 

 

[Suggested language when terminating a call: 
“Thank you very much for your time today. We’re looking to recruiting a wide variety of participants to help with this study. Unfortunately, we have filled participant slots with your specific characteristics. Again, thank you for your interest.”] 

 

INVITATION 

Thank you for answering our questions. We would like to invite you to participate on an audience feedback team.

 

• Are you interested and available to participate?   

 

( ) Yes

(    ) No; THANK AND DISMISS