Attachment E- Gen Adult Qs Form 9600-019

OMB Review Draft

ATTACHMENT E

Screening Questionnaire for General Adult Consumer Focus Group

OMB Control No. 2070-NEW

Approval expires XX/XX/XX

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2070-NEW). Responses to this collection of information are voluntary. 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. The public reporting and recordkeeping burden for this collection of information is estimated to be 0.17 hours per response for screened respondents. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to the Regulatory Support Division Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

Screening Questionnaire for General Adult Consumer Focus Group

Interviewer: _______________ Date: _______________ Letter sent: _______________ Reconfirmation Call: _______________

CALL FROM DATABASE OR AT RANDOM

RECRUIT 9 PER GROUP FOR 8-9 TO SHOW

Hello, I’m __________ with __________________, an independent consumer research firm. We are not selling or promoting any product or service. We are conducting a research study on behalf of the United States Environmental Protection Agency about providing information to help consumers select products that are safer for people, families, and pets and can help protect the environment, and would like to include your views. My questions will take approximately 10 minutes, and your response is voluntary.

1. First, do you, or does any member of your household or immediate family, work for or is retired from:

A market research company _____

A direct mail company or direct marketing company _____

An advertising agency or public relations firm _____

The media (TV/radio/newspapers/magazines) _____

[IF YES TO ANY >> TERMINATE]

2. Are you a chemist, chemical engineer, or organic farmer – or do you work for EPA, an environmental agency or environmental non-profit, or the organic food industry?

[IF YES TO ANY >> TERMINATE]

3. In a typical month, how frequently do you shop at a grocery store, supermarket, hardware store, home improvement store (such as Home Depot or Lowe’s) or general retail store (such as Walmart, Target, Costco, or Sam’s Club) for your household?

4 or more times _____

2 or 3 times _____

TERMINATE >> Fewer than 2 times _____

4. Which of the following categories best describes your total annual household income?

TERMINATE >> Under $15,000 _____

$15,000 - $34,999 _____

$35,000 - $54,999 _____

$55,000 - $74,999 _____

$75,000 - $100,000 _____

TERMINATE >> Over $100,000 _____

5. Please tell me your age.

[Record age; GOOD MIX OF AGES 21+]

6. What is your current marital status? Are you ….. ?

Married or living with a partner_____

Single _____

Divorced _____

Widowed _____

7. What is the highest level of education you have completed?

Less than high school graduate _____

High school graduate _____

Some college _____

College graduate _____

Post graduate studies or degree _____

8. So that we can be sure that all backgrounds are represented in our study, please tell me your ethnic or race background. Are you … ?

Ethnicity

Hispanic or Latino_____

Not Hispanic or Latino_____

Race

American-Indian or Alaska Native _____

Asian _____

Black or African American _____

Native Hawaiian-Indian or Other Pacific Islander _____

White _____

Other _____

9. [Record gender]

Male _____

Female _____

Nonbinary _____

10. Have you ever attended a focus group discussion or individual interview? By that we mean an informal, round-table discussion, conducted by a professional moderator in which you were asked your opinions regarding a product, a service, or advertising?

MAX. ½ GROUP >> ASK A-C >> Yes _____

INVITE TO GROUP >> No _____

1. How many of these groups have you attended?

______________________________ [MAX. 3 EVER]

2. What was/were the topics discussed?

______________________________ [IF CHEMICAL SAFETY, TERMINATE]

3. How long ago was the last one of these groups you attended?

______________________________ [MUST BE AT LEAST 6 MONTHS AGO]

[INVITE TO GROUP]

Thank you for answering all of my questions. As I mentioned earlier, we are conducting a research study regarding information to help consumers select products that are safer for families and can help protect the environment. We are conducting an informal, round-table discussion to be held on _______ at _______. The discussion will last about two hours and will be both fun and informative. No one will attempt to sell you anything and no one will call on you as a result of your participation. As a token of our appreciation for your help in our research effort, you will receive a $100 cash honorarium at the time of the session. This is an important research effort and we hope that you will be part of it. We can only invite about a dozen people to take part. Can we schedule your attendance?

[If yes, read ….. ]

If you need glasses for reading or for watching TV, please be sure to bring them with you to the group.

ID Number _________________________________________________

NAME: _________________________________________________

ADDRESS: _________________________________________________

CITY: _________________________________________________

ZIP CODE: _________________________________________________

PHONE: (DAY) _____________________________________

(EVE) _____________________________________

(CELL) _____________________________________

(EMAIL) _____________________________________

Interviewer: ____________________

Supervisor Confirm: ____________________

EPA Form Number 9600-019

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