Form #1 Form #1 Screener Questionnaire

M

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

edical Expenditure Panel Survey

MEPS Cancer Supplement

Screener for Cognitive Interview Respondents

Hello and thank you for calling about the research opportunity for cancer survivors and those with a current cancer diagnosis. My name is Martha Popovic and I work for Westat, a local research firm. We're doing research for the National Cancer Institute, in partnership with the American Cancer Society, the Centers for Disease Control and Prevention, and the Lance Armstrong Foundation to evaluate a survey questionnaire about the impact of cancer on various aspects of life. If you are eligible and you agree to participate, we will give you $50 to complete an in-person interview that should last about an hour. In order to find out if you are eligible to be interviewed, I need to ask you a few questions.

1. May I go ahead?

• YES

• NO TERMINATE

2. Are you at least 18 years of age?

• YES

• NO  INELIGIBLE

3. How many individual interviews or focus groups have you participated in at Westat or other survey research companies?

• MORE THAN ONE

• ONE

• ZERO  GO TO QUESTION 5

4. When was that?

• IN THE PAST 6 MONTHS

• MORE THAN 6 MONTHS AGO

Public reporting burden for this collection of information is estimated to average 8 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

5. Have you ever been diagnosed with cancer?

• YES

• NO  INELIGIBLE

6. Have you been diagnosed with more than one type of cancer?

• yes – USE “TYPES” IN q7 AND “ANY OF YOUR CANCERS” IN q8

• no – USE “TYPE” IN Q7 AND “YOUR CANCER” IN Q8

7. Please tell me what {type/types} of cancer you’ve been diagnosed with.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

8. Did {your cancer/any of your cancers} ever come back after the first time you were treated for it?

• yes

• no

9. How long ago was your last cancer treatment? Was it…

• Two years ago or less,

• More than two years ago but less than six years ago,

• More than six years ago, or

• Are you currently undergoing cancer treatment?

10. Are you currently working for pay at a job or business?

• YES

• NO  GO TO Q12

11. Are you currently on sick leave or short-term disability?

• YES

• NO

12. Are you currently on long-term disability?

• YES  INELIGIBLE

• NO

RECRUIT A MIX OF DEMOGRAPHIC CHARACTERISTICS FROM Q13-15

13. [RECORD GENDER, IF NOT OBVIOUS, ASK] Are you male or female?

• male

• female

14. Are you Hispanic or Latino/Latina?

• Yes

• NO

15. What is your race? Please select one or more.

• American Indian or Alaska Native

• Asian

• Native Hawaiian or other Pacific Islander

• Black or African American

• White

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

• Less than high school

• Completed 12^th grade/high school graduate

• Some college/2-year college/technical school

• College degree

• Graduate or professional school

17. Are you fluent in Spanish?

• yes  PUT ON LIST FOR SPANISH INTERVIEWS

• no

if ineligible

Thank you very much for your interest, but you are not eligible for this study, or we have already filled the slots you’re eligible for. Thank you very much for your time. We will destroy the information you have provided.

if eligible & waitlist

Thank you for answering all my questions. We may contact you soon to participate in an in-person interview. Can I have your name and phone number so that we can get in touch with you?

Name: ________________________________________

Phone: ________________________________________

if eligible & Scheduling

Thank you for answering all my questions. I’d like to invite you to participate in an in-person interview that will take about an hour to complete. We’ll pay you $50 for your time with us. Let me give you some available times and you tell me what would be best for you.

INTERVIEW DATE AND TIME:

The interview will be held at the Westat facility in Rockville. I would like to send you directions. Where can I send them? Also, may I please have your phone number in case we need to get hold of you for any reason?

COLLECT RESPONDENT NAME, ADDRESS (IF APPLICABLE) AND PHONE

Name: _____________________________________________________________

Address: _____________________________________________________________

City: _________________________________ State: ______ Zip Code: __________

Phone: ________________________________________

In case you need to contact me for any reason, you can reach me at 1-888-670-8106.

800-number message for incoming calls

Hello and thank you for calling about the research opportunity for cancer survivors and those with a current cancer diagnosis. Please leave your name and phone number and we will return your call shortly.

voicemail message for outgoing return calls

Hello, this is Martha Popovic calling from Westat. I’m returning you’re the message you left expressing interest in the research opportunity for cancer survivors and those with a current cancer diagnosis. Please call me back at your earliest convenience, toll-free at 1-888-670-8106