0920-23GT Attachment 2A. CDC BYB FG Screener_English_v4

Form Approved

OMB No. 0920-0800

Expiration Date: 10/31/2024

Project Title: CDC Bring Your Brave

Attachment Title: Focus Group Screener - English

Attachment Number: #2a

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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0800).

Note to recruiter: PLEASE USE THE TERMINATION LANGUAGE BELOW FOR ANY RESPONSE THAT LEADS TO THE ANSWER OPTION “[TERMINATE].”

TERMINATION LANGUAGE: Thank you for taking the time to answer these questions. Unfortunately, based on your answers, you are not eligible to participate in the focus group. There are many possible reasons why people are not eligible. However, thank you for your interest in this study and for taking the time to answer our questions today.

Screener

Hello, my name is [INSERT NAME] from [INSERT FACILITY NAME], a market research firm. We are recruiting for an upcoming study to get feedback related to breast cancer. This is not a sales call of any kind. I am only calling to see if you or an eligible member of your household has an interest in participating in a 90-minute focus group that will be conducted virtually, for which you would receive a $150 incentive.

 

1. Are you interested in seeing if you or anyone in your household qualifies to participate in this focus group? [ACCEPT ONLY 1 PER HOUSEHOLD] 

 

Yes	[  ]	> CONTINUE
No	[  ]	> TERMINATE

 

Great. I have a few questions I need to ask to see if you are qualified for this study. You don’t have to answer any question that you don’t want to answer. 

2. What is your age? _______________ [RECORD VERBATIM] 

TERMINATE IF AGE < 18

TERMINATE IF AGE > 44

3. Which of the following best describes your race? Please tell me all that apply. 

American Indian or Alaska Native	[  ]	> CONTINUE
Asian	[  ]	> CONTINUE
Black or African American	[  ]	> CONTINUE
Native Hawaiian and Other Pacific Islander	[ ]	> CONTINUE
White/Caucasian	[ ]	> CONTINUE
Prefer not the say/Refuse to answer	[ ]	> TERMINATE

*Recruiter: Mixed-race participants are welcome.

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

Yes	[  ]	> CONTINUE
No	[  ]	> CONTINUE

*Recruiter: Participants must identify as American Indian or Alaska Native, Black or African American, or Hispanic/Latino to be included in those specific segments. Mixed-race participants are welcome. For the general population and cisgender LBQA groups, aim to recruit a mix of race and ethnicities.

Recruiter: Only ask questions S5 and S6 if recruiting for the Spanish-speaking focus groups.

5. What language do you usually speak at home? 

Only English	[  ]	> CONTINUE
More English than Spanish	[  ]	> CONTINUE
Both English and Spanish equally	[  ]	> CONTINUE
More Spanish than English	[  ]	> CONTINUE
Only Spanish	[  ]	> CONTINUE

 

6. In what language would you prefer to get health information? 

English	[  ]	> Terminate for Hispanic/Latino group
Spanish	[  ]	> CONTINUE

*Note for Recruiter: If the participant is Hispanic (e.g., answers “yes” to question 4), but prefers to participate in an English language focus group, they can be considered for the general population group.

Note to Hispanic/Latino Spanish-speaking recruitment: 

We will ONLY recruit participants who prefer Spanish. Here is the response option breakdown for the groups segmented by language: 

• English = Only English or More English than Spanish (S5) 

• Spanish = Only Spanish, More Spanish than English, or Both English and Spanish equally (S5) and Spanish (S6) 

7. What is your gender?

Non-binary gender	[  ]	> TERMINATE
Man	[  ]	> TERMINATE
Woman	[  ]	> CONTINUE
Genderqueer or genderfluid	[  ]	> TERMINATE
Agender	[  ]	> TERMINATE
Two-spirit	[  ]	> TERMINATE
Another identity (please write in)	[  ]	> TERMINATE

8. Do you identify as transgender?

Yes	[  ]	> TERMINATE
No	[  ]	> CONTINUE
Not sure	[  ]	> TERMINATE

9. How do you best identify yourself? [Select only one]

Straight	[  ]	> CONTINUE
Gay	[  ]	> CONTINUE
Lesbian	[  ]	> CONTINUE
Bisexual	[  ]	> CONTINUE
Queer	[  ]	> CONTINUE
Pansexual	[  ]	> CONTINUE
On the asexual spectrum	[  ]	> CONTINUE

*IF S9 = 2 (Gay), 3 (Lesbian), 4 (Bisexual), 5 (Queer), 6 (Pansexual), or 7 (on the asexual spectrum), the individual is eligible to participate in the cisgender LBQA focus groups.

10. In the course of your lifetime, have you ever been diagnosed with any of the following cancers?

Breast cancer	[  ]	> TERMINATE
Ovarian cancer	[  ]	> CONTINUE
Liver cancer	[  ]	> CONTINUE
None of the above	[  ]	> CONTINUE

 

*Note for Recruiter: If the participant responded “yes” or “unsure” to a question between S11–S15 and said “no” to S16, then they are eligible for the “unaware of risk” segment.

11. Have any of your blood relatives been diagnosed with ovarian or breast cancer?

Yes, I have a blood relative who has been diagnosed with ovarian and/or breast cancer.	[  ]	> CONTINUE
No, none of my blood relatives have been diagnosed with ovarian and/or breast cancer.	[  ]	> CONTINUE
I’m unsure of my family history and do not know if any blood relatives have been diagnosed with ovarian and/or breast cancer.	[  ]	> CONTINUE

12. Are you of Ashkenazi Jewish heritage?

Yes, I’m of Ashkenazi Jewish heritage.	[  ]	> CONTINUE
No, I’m not of Ashkenazi Jewish heritage.	[  ]	> CONTINUE
I’m unsure of whether I am of Ashkenazi Jewish heritage or not.	[  ]	> CONTINUE

13. Have you received radiation therapy to the breast or chest during childhood or early adulthood?

Yes, I have received radiation therapy to the breast or chest during childhood or early adulthood.	[  ]	> CONTINUE
No, I have not received radiation therapy to the breast or chest during childhood or early adulthood.	[  ]	> CONTINUE
I’m unsure if I have received radiation therapy to the breast or chest during childhood or early adulthood.	[  ]	> CONTINUE

14. Have you had breast problems, such as lobular carcinoma in situ (LCIS), ductal carcinoma in situ (DCIS), atypical ductal hyperplasia, or atypical lobular hyperplasia?

Yes, I have had breast problems, such as lobular carcinoma in situ (LCIS), ductal carcinoma in situ (DCIS), atypical ductal hyperplasia, or atypical lobular hyperplasia.	[  ]	> CONTINUE
No, I have not had breast problems, such as lobular carcinoma in situ (LCIS), ductal carcinoma in situ (DCIS), atypical ductal hyperplasia, or atypical lobular hyperplasia.	[  ]	> CONTINUE
I’m unsure if I have had breast problems, such as lobular carcinoma in situ (LCIS), ductal carcinoma in situ (DCIS), atypical ductal hyperplasia, or atypical lobular hyperplasia have received radiation therapy to the breast or chest during childhood or early adulthood.	[  ]	> CONTINUE

15. Have you been told that you have dense breasts on a mammogram?

Yes, I have been told that I have dense breasts on a mammogram.	[  ]	> CONTINUE
No, I have not been told that I have dense breasts on a mammogram.	[  ]	> CONTINUE
I’m unsure if I have been told that I have dense breasts on a mammogram or not.	[  ]	> CONTINUE
I’ve never had a mammogram.	[ ]	> CONTINUE

16. Have you taken any steps to better understand your risk for breast cancer?

Yes, I have taken steps to better understand my risk for breast cancer.	[  ]	> CONTINUE to S17
No, I have not taken any steps to better understand my risk for breast cancer.	[  ]	> CONTINUE to S19
Unsure	[  ]	> CONTINUE TO S19

*Note for Recruiter: If the participant responded “yes” or “unsure” to a question between S11–S15 and said “no” to S16, then they are within the “Unaware of Risk” segment and should proceed to S19.

If participant responded “yes” to S16, continue to S17 to determine “previvor” status.

17. Have you gone through genetic counseling and testing to better understand your risk for breast cancer?

Yes, I have gone through genetic counseling to better understand my risk for breast cancer.	[  ]	> CONTINUE to S18
No, I have not gone through genetic counseling to better understand my risk for breast cancer.	[  ]	> Terminate
Unsure	[  ]	> Terminate

*IF S17 = yes, continue as the Previvor segment.

18. ASK ONLY IF S17 = 1: After undergoing genetic counseling, did you receive results for a genetic mutation, such as BRCA1, BRCA2, PALB2, or other hereditary genetic mutations that put you at risk for breast cancer?

Yes, I have a genetic mutation that puts me at risk for breast cancer.	[  ]	> CONTINUE
No, I do not have a genetic mutation that puts me at risk for breast cancer.	[  ]	> Terminate

*If S18 = yes, this individual is eligible to participate in the previvor group.

19. In the past 5 years, have you or has a member of your immediate family worked in any of the following fields, companies, or organizations? 

Market or public opinion research	[  ]	> TERMINATE
An advertising, public relations, marketing, or digital media agency	[  ]	> TERMINATE
News, radio, TV, print, media	[  ]	> TERMINATE
As a health care provider or medical professional (e.g., physician, nurse)	[  ]	> TERMINATE
At a health care company (e.g., health insurance company, hospital)	[  ]	> TERMINATE
None of these	[  ]	> CONTINUE

 

20. Have you participated in any 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 6 months?

    Yes	[  ]	> TERMINATE
    No	[  ]	> CONTINUE

21. In order to participate, you need to have a desktop or laptop computer or a smartphone with an internet connection. You will also need to consent to being recorded during the focus group. Will you be able to meet both of these requirements? 

Yes	[  ]	> CONTINUE
No	[  ]	> TERMINATE

 

22. Would you be willing and able to participate in this study via a webcam or smartphone camera? 

Yes	[  ]	> CONTINUE  (prioritize)
No	[  ]	> CONTINUE

 

23. In what city and state do you live?    

CITY: ________________       STATE:_____________________ 

Note to recruitment: Recruit a mix of locations. 

 

24. Which one of the following best describes the area of your home?

Rural	[  ]	> CONTINUE
Suburban	[  ]	> CONTINUE
Urban	[  ]	> CONTINUE

25. In what country were you born?    

COUNTRY:_______________

26. What is the highest level of school you have completed? [RECRUIT A MIX] 

Some H.S. or less (no diploma)	[  ]	> CONTINUE
H.S. diploma or H.S. equivalent (GED)	[  ]	> CONTINUE
Some college, no degree	[  ]	> CONTINUE
Associate degree	[  ]	> CONTINUE
Bachelor’s degree	[  ]	> CONTINUE
Master’s degree	[  ]	> CONTINUE
Professional or doctorate degree	[  ]	> CONTINUE

   

27. Last year—that is, in 2021—what was your total household income from all sources, before taxes? [RECRUIT A MIX, ENSURE ROBUST REPRESENTATION OF <$50K] 

Less than $15,000	[  ]	> CONTINUE
$15,000 to $24,999	[  ]	> CONTINUE
$25,000 to $34,999	[  ]	> CONTINUE
$35,000 to $49,999	[  ]	> CONTINUE
$50,000 to $74,999	[  ]	> CONTINUE
$75,000 to $99,999	[  ]	> CONTINUE
$100,000 to $149,999	[  ]	> CONTINUE
$150,000 to $199,999	[  ]	> CONTINUE
$200,000 and over	[  ]	> CONTINUE
Don’t know/Refused	[  ]	> CONTINUE

 

28. Do you have any kind of health care coverage, including health insurance, a prepaid plan like an HMO, or a government plan like Medicare or Indian Health Service?

Yes	[  ]	> CONTINUE
No	[  ]	> CONTINUE
Don’t know/Refused	[  ]	> CONTINUE

29. Do you have one person you think of as your doctor or health care provider?

Yes	[  ]	> CONTINUE
No	[  ]	> CONTINUE
Don’t know/Refused	[  ]	> CONTINUE

Thank you for taking the time to answer these questions. If you are chosen for the project, a team member will contact you to arrange a convenient time for the interview. We will be in touch with additional information on the study. The virtual focus group will last no longer than 90 minutes. [Recruitment facility to coordinate with participant on scheduling]

***** 

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