Form 0920-22HW Screening Questionnaire

Attachment I: Household/ Screener Questionnaire

Form Approved

OMB No: 0920-xxxx
Exp. Date: xx-xx-xxxx

Public Reporting burden of this collection of information is estimated at 3 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 Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA  30333; Attn:  PRA (0920-xxxx) or byws@cdc.gov.

In-Person Household (to be administered to households who do not complete web screener)

INTRODUCTION: I am a survey interviewer from NORC at the University of Chicago for a research study supported by [Baltimore City Health Department/Garrett County] in partnership with the U.S. Centers for Disease Control and Prevention. We are conducting a survey in your area on the health, educational, and life experiences of young people in [Baltimore/Garrett County]. In order to administer the survey, I will first need to identify all of the people who live in this household, but I am not going to write down any names. If you agree, I will start by listing all persons who usually live in your household and visitors who are currently living here, recording their age, date of birth and sex. Please do not tell me their name. Depending on the outcomes of the recording and selection, I will request to speak with the head of household and a member of the household between the ages of 13 and 24 years who has been randomly selected to participate.

For the purposes of this survey, a household is a group of people who live and sleep together in one unit and share most meals together. We consider someone a household member as long as they have been here at least 6 weeks and have plans to stay. If there are youth in this household who attend boarding school or college and live on campus while class is in session, we would consider them a household member as long as they consider this their main household and return to this household during school breaks and holidays.

The list should NOT include VISITORS, and only include people who have lived in this home for at least 6 weeks with plans to stay, or those that recently moved and are intending to stay.

HOUSEHOLD LISTING

READ: Please, could you identify all of the people who live in this home, starting with the oldest one? Please don’t tell me their names. You only have to tell me their age(s), date(s) of birth and what gender they.
	Age of HOH	Date of birth of HOH (Day/Month/Year)	What is the Gender of the Head of the Household? (1=Male, 2= Female, 3 Does not identify as Male or Female	[For only those who do not identify either as male or female] What Gender was the Head of Household assigned at birth, on their original birth certificate? (1=Male, 2=Female)
Head of Household
Household Member	Age of this Household Member	Date of birth of this Household Member (Day/Month/Year)	What is the Gender of this Household Member? (1=Male, 2= Female, 3=Do not identify as either Male or Female)		[For only those who do not identify either as male or female] What Gender was this household member assigned at birth, on their original birth certificate? (1=Male, 2=Female)
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[IF NO ELIGIBLE PARTICIPANT]: Thank you for taking the time to complete this information. There is no eligible participant in this household.

[IF ELIGIBLE PARTICIPANT] Your household is eligible to continue. [CONTINUE TO HEAD OF HOUSEHOLD CONSENT]

Attachment I: Household/Web Screener

Web Screener (to be completed online)

INTRODUCTION: NORC at the University of Chicago is conducting a research study supported by [Baltimore City/Garrett County Health Department] in partnership with the U.S. Centers for Disease Control and Prevention. The study is about the health, educational, and life experiences of young people in [Baltimore/Garrett County]. Before administering the survey, the research team will need to identify all of the people who live in this household. Please list all persons who usually live in your household and visitors who are currently living here, recording their age, date of birth and sex. Depending on the outcomes of the recording and selection, an interviewer will visit your home to request to speak with the head of household and a member of the household between the ages of 13 and 24 years who has been randomly selected to participate.

For the purposes of this survey, a household is a group of people who live and sleep together in one unit, answer to one main head of household, and share most meals together. Someone is considered a household member as long as they have been here at least 6 weeks and have plans to stay. If there are youth in this household who attend boarding school or college and live on campus while class is in session, we would consider them a household member as long as they consider this their main household and return to this household during school breaks and holidays.

The list should NOT include VISITORS, and only include people who have lived in this home for at least 6 weeks with plans to stay, or those that recently moved and are intending to stay.

HOUSEHOLD LISTING

READ: Please, could you identify all of the people who live in this home, starting with the oldest one? Please don’t tell me their names. You only have to tell me their age(s), date(s) of birth and what gender they are.
	Age of HOH	Date of birth of HOH (Day/Month/Year)	What is the Gender of the Head of the Household? (1=Male, 2= Female, 3 Does not identify as Male or Female	[For only those who do not identify either as male or female] What Gender was this Head of Household assigned at birth, on their original birth certificate? (1=Male, 2=Female)
Head of Household
Household Member	Age of this Household Member	Date of birth of this Household Member (Day/Month/Year)	What is the Gender of this Household Member? (1=Male, 2= Female, 3=Do not identify as either Male or Female)		[For only those who do not identify either as male or female] What Gender was this household member assigned at birth, on their original birth certificate? (1=Male, 2=Female)
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Attachment I: Household/Web Screener

Phone Screener (to be completed when an individual calls the toll free number)

INTRODUCTION: Hello and thank you for calling NORC at the University of Chicago for the youth health survey screening. This screening will only take two to five minutes to assess the numbers of individuals living in your household and their ages. To give you more information about this study, NORC at the University of Chicago is conducting a research study supported by [Baltimore City/Garrett County Health Department] in partnership with the U.S. Centers for Disease Control and Prevention. The study is about the health, educational, and life experiences of young people in [Baltimore/Garrett County]. Before administering the survey, the research team will need to identify all of the people who live in this household.

For the purposes of this survey, a household is a group of people who live and sleep together in one unit and share most meals together. Someone is considered a household member as long as they have been here at least 6 weeks and have plans to stay. If there are youth in this household who attend boarding school or college and live on campus while class is in session, we would consider them a household member as long as they consider this their main household and return to this household during school breaks and holidays.

Now I’m going to ask you to list all persons who usually live in your household and visitors who are currently living here, recording their age, date of birth and sex. Depending on the outcomes of the recording and selection, an interviewer will visit your home to request to speak with the head of household and a member of the household between the ages of 13 and 24 years who has been randomly selected to participate.

The list should NOT include VISITORS, and only include people who have lived in this home for at least 6 weeks with plans to stay, or those that recently moved and are intending to stay.

HOUSEHOLD LISTING

READ: Please, could you identify all of the people who live in this home, starting with the oldest one? Please don’t tell me their names. You only have to tell me their age(s), their date(s) of birth and what gender they are.
Head of Household	Age of HOH	Date of birth of HOH (Day/Month/Year)	What is the Gender of the Head of the Household? (1=Male, 2= Female, 3 Does not identify as Male or Female)	[For only those who do not identify either as male or female] What Gender was this Head of Household assigned at birth, on their original birth certificate? (1=Male, 2=Female)
Household Member	Age of this Household Member	Date of birth of this Household Member (Day/Month/Year)	What is the Gender of this Household Member? (1=Male, 2= Female, 3=Do not identify as either Male or Female)		[For only those who do not identify either as male or female] What Gender was this household member assigned at birth, on their original birth certificate? (1=Male, 2=Female)
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[IF NO ELIGIBLE PARTICIPANT]: Thank you for taking the time to complete this information. There is no eligible participant in this household.

[IF ELIGIBLE PARTICIPANT] We would like to schedule an interview with your household! Please provide your preferred contact method so that we may contact you to schedule an interview.

Phone: _________________________

Email: __________________________

How would you prefer that we contact you? ☐text message ☐phone call ☐email

What is the best time for us to reach you? Select all times with a check mark (ü) that you are typically available below.

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Morning
Afternoon
Evening