Form 0920-25-0124 Lyme Disease Screener

Form Approved

OMB Control No.: 0920-1154

Expiration date: 03/31/2026

CDC National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)

Recruitment Screener for Lyme Disease Focus Groups

Updated: May 13, 2025

Hello. My name is ________ and I’m calling from _________, an independent communications firm.

You indicated that you are interested in participating in a focus group conversation on topics that may matter or be interesting to you. [DO NOT DISCLOSE THE EXACT TOPIC OF DISCUSSION BEFORE THE FOCUS GROUP.] The discussion will last approximately 90 minutes. The sole sponsor of this activity is the Centers for Disease Control and Prevention (CDC). To maintain participants’ confidentiality, the leader will use first names only during the discussion, and no part of your name will be used in any transcripts or reports available to CDC. CDC is not interested in any of your personal information. At this stage, we will be asking you a few questions to ensure we are recruiting a variety of people only.

I have a few questions to start.

[IF TERMINATED DURING SCREENING PROCESS, READ:] I’m sorry, we already have enough individuals in that category. Thank you very much for your time.

INTERVIEWER INSTRUCTION: If an individual expresses concern at any point during the screening process, please note their concern and reassure them appropriately. Remind them that their answers and participation will be completely confidential.

Name: _______________________________________________________

Address (residence): _______________________________________________________

City, State, ZIP: _______________________________________________________

Phone: _______________________________________________________

Email: _______________________________________________________

Recruiter: _______________________________________________________

SEPARATE CONTACT SHEET FROM THE REST OF THE SCREENER AND SHRED AT THE END OF THE PROJECT.

Recruit Summary & Criteria

Segment	Audience	FGs / Recruits
A	High incidence states: high intensity outdoor enthusiasts	1 / 8
B	High incidence states: low intensity outdoor enthusiasts	1 / 8
C	High incidence states: parents of children ages 5-10	1 / 8
D	High incidence states: parents of children ages 11-15	1 / 8
E	Emerging incidence states: high intensity outdoor enthusiasts	1 / 8
F	Emerging incidence states: low intensity outdoor enthusiasts	1 / 8
G	Emerging incidence states: parents of children ages 5-10	1 / 8
H	Emerging incidence states: parents of children ages 11-15	1 / 8
Total		8 / 64

1. All participants must live in either a High Incidence or an Emerging Incidence state.

   High Incidence States (4 groups):	Emerging Incidence States (4 groups):
   Currently lives in: Connecticut, Delaware, D.C., Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, West Virginia, or Wisconsin	Currently lives in: North Carolina, Ohio, Iowa, Illinois, Michigan, or Indiana .
   Note: For each group, we will recruit no more than 2 participants from the same state.

2. Both the High Incidence and Emerging Incidence groups will include each of the four group categories and criteria. Note: If a participant qualifies for both the activity and parent groups, please place them in whichever group has more of a recruitment need.

   High intensity outdoor enthusiasts (1 group):

   • Have participated in any of the following activities 6+ times from May to October 2024 (and plan to do so with similar frequency in May to October 2025): Hiking, Camping, Trail running, Mountain biking

   Low intensity outdoor enthusiasts (1 group):

   • Have participated in any of the following activities 6+ times from May to October 2024 (and plan to do so with similar frequency in May to October 2025): Yardwork and gardening, Park visits and walks, Picnicking, Bird watching, Golfing, Sports in parks or nature, Casual bike rides in parks or nature

   Parents of children aged 5-10 (1 group):

   • Parent to a child between the ages of 5-10 who is regularly active outdoors during warmer months – May through October.

   Parents of children aged 11-15 (1 group):

   • Parent to a child between the ages of 11-15 who is regularly active outdoors during warmer months – May through October.

3. Each of the eight groups must include a minimum of 3 participants with a dog that is active outdoors (this can include dog walkers).

Screening Questions

1. What is your age? [RECORD EXACT AGE; DO NOT READ LIST]

Under 18		TERMINATE
18-29		RECORD RECRUIT A MIX
30-39	
40-49	
50-59	
60 or older	

2. How many times within the past six months have you participated in a focus group or one-on-one interview on a healthcare topic? DO NOT READ RESPONSE CATEGORY

None		CONTINUE
One	
2 or more		TERMINATE

3. Do you, a spouse or partner, or a child work in any of the following fields? 

Market research, advertising or communications		TERMINATE ALL
Health care or public health	
Pharmaceuticals, health sciences, or medical device manufacturing	
Federal or state government	
None of the above		CONTINUE

4. In what state do you live? RECORD STATE, ALSO CODE TO TABLE. Note: For each group, recruit no more than 2 participants from the same state.

High Incidence States Connecticut Delaware D.C. Maine Maryland Massachusetts Minnesota New Hampshire New Jersey New York Pennsylvania Rhode Island Vermont Virginia West Virginia Wisconsin		QUALIFIES FOR HIGH INCIDENCE GROUPS RECRUIT MIX MAX 2 OF EACH STATE PER GROUP
Emerging-Incidence States North Carolina Ohio Iowa Illinois Michigan Indiana		QUALIFIES FOR EMERGING-INCIDENCE GROUPS RECRUIT MIX MAX 2 OF EACH STATE PER GROUP
Other		TERMINATE

5. Do you participate in any outdoor activities with a dog during warmer months – May through October (e.g., going on walks, hiking, playing fetch in the backyard, etc.)? 

Yes		PROBE AND RECORD WHICH ACTIVITIES MIN 3 PER GROUP
No		CONTINUE

6. Between May and October 2024, did you participate in any of the following activities? Choose all that apply. RECORD ACTIVITIES Note: If both high and low activities are mentioned, place participant in high intensity groups. Each low intensity group must include at least four activities represented in total amongst participants.

Hiking Camping Trail running Mountain biking		CONTINUE TO HIGH INTENSITY ACTIVITY GROUPS
Yardwork and gardening Park visits and walks Picnicking Bird watching Golfing Sports in parks or nature Casual bike rides in parks or nature		CONTINUE TO LOW INTENSITY ACTIVITY GROUPS MIN 4 OF EACH ACTIVITY PER GROUP
None		SKIP TO Q9

7. Between May and October 2024, how many times did you participate in any of the activities you selected? Your best estimate is fine. RECORD FOR EACH ACTIVITY SELECTED Note: Must be six or more times, and total amount can be from across multiple activities.

Once or twice		SKIP TO Q9
Three to five times	
Six to 10 times		FOR ACTIVITY GROUPS, MUST SELECT TO CONTINUE
More than 10 times	

8. Between May and October 2025, do you plan to participate in any of these activities less, the same amount, or more frequently?

Less frequently		SKIP TO Q9
Same		FOR ACTIVITY GROUPS, MUST SELECT TO CONTINUE QUALIFIES FOR HIGH INTENSITY ACTIVITY OR LOW INTENSITY ACTIVITY GROUPS
More frequently	

9. Are you a parent or full-time guardian of at least one child age 5 to 15?

Yes		CONTINUE
No		TERMINATE IF NOT QUALIFIED FOR ACTIVITY GROUP

10. [ASK IF PARENT] Is your child regularly active outdoors between the months of May and October? Regularly active means being outside (e.g., playing sports, going to the park, playing in the grass or forest, etc.) for extended periods of time at least once a month.

Yes		CONTINUE
No		TERMINATE IF NOT QUALIFIED FOR ACTIVITY GROUP

11. [ASK IF PARENT] How old is your child that is between the ages of 5 to 15? If you have more than one child in this age range, please share all ages RECORD ALL Note: If participant has multiple children in both age groups, assign participant to group with more of a recruitment need.

5		QUALIFIES FOR PARENTS 5-10 GROUP RECRUIT MIX
6	
7	
8	
9	
10	
11		QUALIFIES FOR PARENTS 11-15 GROUP RECRUIT MIX
12	
13	
14	
15	

Finally, to ensure we understand the individuals who are answering these questions… 

12. What is your sex?

Female		RECRUIT A MIX
Male	

13. What is your race or ethnicity? Select all that apply. MULTISELECT

American Indian or Alaska Native For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.		RECRUIT A MIX
Asian For example, Chinese, Asian Indian, Filipino, Vietnamese, Korea, Japanese, etc.	
Black or African America For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.	
Hispanic or Latino For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.	
Middle Eastern or North African For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.	
Native Hawaiian or Pacific Islander For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.	
White For example, English, German, Irish, Italian, Polish, Scottish, etc.	

14. Which of the following includes your total annual household income for the last year?

Less than $20,000		RECRUIT A MIX
$20,000 to less than $30,000	
$30,000 to less than $40,000	
$40,000 to less than $50,000	
$50,000 to less than $60,000	
$60,000 to less than $70,000	
$70,000 to less than $80,000	
$80,000 to less than $90,000	
$90,000 to less than $100,000	
$100,000 or more	

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

Less than high school graduate		RECRUIT A MIX
High school graduate or completed GED	
Technical or vocational degree	
Four-year college degree	
Postgraduate or professional degree	

16. Would you describe the area that you live in as urban, rural, suburban, or a small town?

Rural		RECORD
Suburban	
Small town	
Urban	

Invitation

Thank you for answering all of my questions. As I mentioned, we respect your privacy and understand this information is confidential, and we will not disclose this information to anyone outside of the project team. We asked these questions because we want to speak with a wide variety of people who can review important information and provide their feedback. Based on your answers to the questions, we would like to invite you to participate in a 90-minute focus group.

You will receive $75 as a token of appreciation for your participation, which will be provided to you after you complete the focus group.

All of your feedback will be confidential, never in association with your name. To make sure we capture your remarks accurately, we will audio and video record the discussion. The purpose of the recording is to make sure we report accurately, we will not include your name in the transcript. After approval of the final report, recordings will be deleted. Is this discussion something you are interested in and comfortable with?

Yes		SHARE DATE AND TIME OF FG
No		TERMINATE

Additionally, the focus group is virtual, meaning that you can participate from the comfort of your home or office. You will not need to come to a facility, and can meet us virtually from wherever you are, but you will need to be in front of a computer or tablet with internet access and camera so you can be on screen. (You may not participate on a cell phone.) You will also have to be in a quiet place. Someone will contact you before the focus group to make sure all the technology needed for the discussion is working properly. Is this something you are interested in and comfortable with, and do you have access to a computer or tablet to fulfill these requirements?

Yes		CONTINUE
No		TERMINATE

FOR SCHEDULED PARTICIPANTS:

The focus group will occur on DATE at TIME. Before your scheduled discussion, we will send you confirmation with all the required logistical and technological information. If you wear reading glasses or use a hearing aid, please remember to have those with you at the focus group.

If you must cancel, please let us know immediately, so we can find someone to take your place. My name is ___________ and you can reach me at _____________.

SEPARATE FIRST PAGE (CONTACT SHEET) AND SHRED AT THE END OF THE PROJECT

Public reporting burden of 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 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 NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA 0920-1154

CDC NCEZID Lyme Disease Screener 1