Participant Screener

Attachment C

Participant Screener

Form Approved

OMB No. 0920-0572

Exp. Date: 3/31/2018

Public Reporting burden of this collection of information is estimated at 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 NW, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-0572).

Screening Script and Questionnaire

Hello, my name is __________, and I'm with <Focus Pointe>, a research organization that is working with researchers at Battelle and the Centers for Disease Control and Prevention or CDC. We’re working with CDC to gather feedback on the My Mobility brochure and to get ideas on how to distribute it. The tool is designed to help people ages 60 or older protect their ability to get places they need to go as they age. May I please speak to [NAME]?

• Yes. (REPEAT INTRO IF NECESSARY AND PROCEED)

• No Answer. (Leave a message as appropriate and follow-up later)

Hello [NAME] We’re looking for people to participate in a 2 hour focus group in ___MONTH_______of YEAR. If you are eligible to participate, you may take part in a focus group discussion with 4-6 people.

If you are interested, I will ask you a few questions to determine if you are eligible for the project. Your participation is completely voluntary, and all the information you provide will be kept private and secure. If you do not wish to provide this information, you are free to stop these questions at any time.

What is your age?	_______	If not between 60-74 (terminate)
How would you describe your ability to get where you need to go on a typical day? Would you say it is very good, good, fair, or poor?	☐ Very good ☐ Good ☐ Fair (terminate) ☐ Poor (terminate)
Do you currently live in a retirement community, nursing home, assisted living residence or facility, a skilled nursing facility, or in some other assisted living situation?	☐ Yes (terminate)	☐ No (continue)
Do you ever use the Internet for health information?	☐ Yes (go to question #5)	☐ No (record as Non-internet, go to question #5)
(If “Yes” to #4): About how often do you use the Internet?	☐ Several times a day ☐ About once a day ☐ 3-5 days a week ☐ 1-2 days a week ☐ Every few weeks (record as Internet User)	☐ Less often ☐ Never ☐ Don’t know/refused (record as Non-internet)

Based on your responses so far, I would like to invite you to participate in this project. This project will require a 2 hour appointment at one of Battelle’s research offices. During the appointment, you and 4-5 other people will participate in a group discussion. You will receive $75 in cash for your participation.

Are you willing to commit to a 2 hour appointment to participate in the project?	☐ Yes (continue)	☐ No (terminate)
The focus group will be recorded so that the researchers do not have to take detailed notes. Are you comfortable with the researchers recording the focus group?	☐ Yes (continue)	☐ No (terminate)
Most of the discussion will involve speaking and reading in English. Are you comfortable with speaking and reading in English?	☐ Yes (continue)	☐ No (terminate)
(Discuss available times, and schedule as appropriate)	___________________________ Date/Time Visit 1 ___________________________ Date/Time Visit 2 ___________________________ Date/Time Visit 3
(Verify Personal/Contact information, update as needed)	Name Phone Confirm address (for mailing letter and advance copy of MPT)
(Record the following items for tracking purposes)	Date of Birth Now I’d like to ask you some general questions about your background. Are you of Hispanic or Latino/Latina origin or descent? Yes No Which of the following best describes your race? Select all that apply [READ LIST:] American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, or White ASK IF NOT OBVIOUS: What sex were you assigned at birth, on your original birth certificate? ☐ Male ☐ Female What is the highest grade or year of school that you completed? RECORD RESPONSE: Less than High School Degree or GED High School Degree or GED only Some college (no degree) Completed associate or other technical 2-year degree Completed Bachelor’s degree (but not graduate or professional degree) Completed graduate or professional degree (Master’s degree or higher) 5. Do you wear eyeglasses, contacts lenses, or any kind of corrective eyewear? ☐ Yes ☐ No 6. Have you been diagnosed as colorblind or color deficient? ☐ Yes ☐ No

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