Form 0920-1050 Participant Screener (English Groups)

OMB Control No. 0920-1050

Exp. Date 05/31/2022

Public reporting burden of this collection of information is estimated to average 5 minutes per respondent. 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia, 30333; ATTN: PRA (0920-1050).

Attachment M. Participant Screeners

Participant Screener (English Groups)

The participant screener will take place over the phone:

Hello [NAME] We’re looking for people to participate in a 90-minute focus group in _______MONTH _______of YEAR. If you are interested, I will ask you a few questions to determine if you are eligible to participate.

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. If you are eligible to participate, you may take part in a focus group discussion with 5-8 people.

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? For example, how easy is it for you to get around town? Would you say it is very good, good, fair, or poor?	☐ Very good (continue) ☐ Good (continue) ☐ Fair (continue) ☐ Poor (terminate)
Do you currently live in a nursing home, assisted living residence or facility or skilled nursing facility?	☐ Yes (terminate)	☐ No (continue)
Do you have high-speed internet access?	☐ Yes (continue)	☐ No (terminate)
Do you have a computer, tablet, or phone that you can use to participate in a virtual meeting?	☐ Yes (continue)	☐ No (terminate)
Does your internet access support online video conferencing through Zoom?	☐ Yes (continue) ☐ No (terminate) ☐ Don’t Know (terminate)
Do you have access to an active email account that you can use to receive notices about the study? This account is where we will send your confirmation email with important instructions on how to join the session.	☐ Yes (continue)	☐ No (terminate)
Do you currently take any prescription medicines for a health condition?	☐ Yes (Aim to include 5 to 7 individuals currently taking prescription medicines)	☐ No (Include no more than 2 individuals currently not taking prescription medicines)

Termination Language (if needed): Thank you for your time and for completing the screening process. Based on your responses, you are not eligible to participate in this project. We will contact you further if your responses seem to be a good match for future projects.

Based on your responses so far, you are eligible to participate in this project. If you agree to participate in this project, we will ask you to take part in a 90-minute online, video group discussion. During the session, you and 5-8 other people will take part in a group discussion. You will receive a $75 token of appreciation for your participation.

Are you willing to commit to a 90-minute online, video group discussion to participate in the project?	☐ Yes (continue)	☐ No (terminate)
The group discussion 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)
What is what is your native language?	☐ English (continue to Question 12) ☐ Spanish (continue to Question 13) ☐ Other Languages (continue to question 12)
[Use this question only for recruitment for English participants] Most of the discussion will involve speaking and reading in English. Are you comfortable with speaking and reading in English?	☐ Yes (assign to English group)	☐ No (terminate)
[Use this question only for recruitment for Spanish participants] Most of the discussion will involve speaking and reading in Spanish. Are you comfortable with speaking and reading in Spanish?	☐ Yes (assign to Spanish group)	☐ No (terminate)
What is your Zip Code?	Use the Am I Rural? Tool - Rural Health Information Hub tool to check Zip code and apply the Federal Office of Rural Health Policy (FORHP) standard to define rural areas ☐ Rural (assign to Rural Spanish or English Group) ☐ Urban or Suburban (assign to Urban/Suburban Spanish or English Group)
(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 Email Address City, State, Zip Confirm address for mailing letter and advance copy of MPP Resources
(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? You may choose more than one [READ LIST:] American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, or White [Recruit at least to one Black/African American and one Asian participant per group] What sex were you assigned at birth, on your original birth certificate? Male Female Prefer not to answer (do not read this answer aloud) How do you describe your gender identity? Male Female Male-to-female transgender (MTF) Female-to-male transgender (FTM) Other gender identity (specify): __________ Prefer not to answer (do not read this answer aloud) [Aim to recruit at least three males per group and three females per group] 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) [Recruit at least one person that has HS degree or less]

Quotas for English and Spanish Groups

Prescription Medications	Currently taking prescription medicine- Include 5 to 7 per group	Currently not taking prescription medicine- Include no more than 2 individuals per group
Race/Ethnicity	Black/African American- Recruit at least 1 participant per group	Asian- Recruit at least 1 participant per group
Gender	Males- Recruit at least 3 per group	Females- Recruit at least 3 per group
Education	HS degree or less- At least 1 participant per group

Thank you for your participation. After this call, you will receive a statement of participation via email. Included with that statement of participation will be four PDF documents, which we would like you review before our online session, as well as some instructions on what to consider about them as read the documents. We will also mail you a copy of the materials. Thank You.

Participant Screener (Spanish Groups)

The participant screener will take place over the phone:

Hola, [NOMBRE]. Estamos buscando personas para participar en una discusión grupal de 90 minutos en _______ MES_______del AÑO. Si está interesado, le haré algunas preguntas para determinar si puede participar.

Su participación es completamente voluntaria y toda la información que proporcione se mantendrá privada y segura. Si no desea proporcionar esta información, puede dejar de responder a estas preguntas en cualquier momento. Si reúne los requisitos para participar, podrá participar en una discusión grupal con entre cinco y ocho personas.

¿Cuál es su edad?	_______	If not between 60-74 (terminate)
¿Cómo describiría su capacidad para llegar a donde necesita ir en un día normal? Por ejemplo, ¿qué facilidad tiene para desplazarse por la ciudad? ¿Diría que es muy buena, buena, regular o mala?	☐ Muy buena (continue) ☐ Buena (continue) ☐ Regular (continue) ☐ Mala (terminate)
¿Vive actualmente en una residencia de ancianos, en una residencia o centro de vida asistida o en un centro de enfermería especializado?	☐ Sí (terminate)	☐ No (continue)
¿Tiene acceso a el Internet de alta velocidad?	☐ Sí (continue)	☐ No (terminate)
¿Tiene una computadora, una tableta o un teléfono que pueda utilizar para participar en una reunión virtual?	☐ Sí (continue)	☐ No (terminate)
¿Su acceso a el Internet permite realizar videoconferencias a través de Zoom?	☐ Sí (continue) ☐ No (terminate) ☐ No lo sé (terminate)
¿Tiene acceso a una cuenta de correo electrónico activa que pueda utilizar para recibir avisos sobre el estudio? A esta cuenta le enviaremos su correo electrónico de confirmación con instrucciones importantes sobre cómo unirse a la sesión.	☐ Sí (continue)	☐ No (terminate)
¿Toma actualmente algún medicamento recetado para alguna enfermedad?	☐ Sí (Aim to include 5 to 7 individuals currently taking prescription medicines)	☐ No (Include no more than 2 individuals currently not taking prescription medicines)

Termination Language (if needed): Gracias por su tiempo y por completar el proceso de selección. Según sus respuestas, no puede participar en este proyecto. Nos comunicaremos con usted más adelante si sus respuestas parecen encajar en futuros proyectos.

Según sus respuestas hasta ahora, cumple los requisitos para participar en este proyecto. Si acepta participar en él, le pediremos que participe en una discusión grupal por Internet y por video de 90 minutos de duración. Durante la sesión, usted y otras cinco u ocho personas participarán en una discusión grupal. Recibirá una muestra de agradecimiento de $75 dólares por su participación.

¿Está dispuesto a comprometerse a participar en una discusión grupal de 90 minutos por el Internet mediante video?	☐ Sí (continue)	☐ No (terminate)
La discusión grupal se grabará para que los investigadores no tengan que tomar notas detalladas. ¿Le parece bien que los investigadores graben la discusión grupal?	☐ Sí (continue)	☐ No (terminate)
¿Cuál es su lengua materna?	☐ Inglés (continue to Question 12) ☐ Español (continueto Question 13) ☐ Otros idiomas (continue to question 12)
[Use this question only for recruitment for English participants] La mayor parte de la discusión requerirá hablar y leer en inglés. ¿Se siente cómodo hablando y leyendo en inglés?	☐ Sí (assign to English group)	☐ No (terminate)
[Use this question only for recruitment for Spanish participants] La mayor parte de la discusión requerirá hablar y leer en español. ¿Se siente cómodo hablando y leyendo en español?	☐ Sí (assign to Spanish group)	☐ No (terminate)
¿Cuál es su código postal?	Use the Am I Rural? Tool - Rural Health Information Hub tool to check Zip code and apply the Federal Office of Rural Health Policy (FORHP) standard to define rural areas ☐Rural (assign to Rural Spanish or English Group) ☐Urban or Suburban (assign to Urban/Suburban Spanish or English Group)
(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)	Nombre Teléfono Correo electrónico Dirección Ciudad, Estado, Código postal Confirm address for mailing letter and advance copy of MPP Resources
(Record the following items for tracking purposes)	Fecha de nacimiento Ahora me gustaría hacerle algunas preguntas generales sobre sus orígenes. ¿Es usted de origen o descendencia hispana o latina? Sí No ¿Cuál de las siguientes opciones describe mejor su raza? Puede elegir más de una [LEA LA LISTA:] Indio americano o nativo de Alaska, Asiático, Negro o afroamericano, Hawaiano nativo u otra raza Isleña del Pacífico, o Blanco [Recruit at least to one Black/African American and one Asian participant per group] ¿Qué sexo se le asignó al nacer, en su certificado de nacimiento original? Hombre Mujer Prefiero no contestar (no lea esta respuesta en voz alta) ¿Actualmente se describe como hombre, mujer o transgénero? Hombre Mujer Transgénero de hombre a mujer (MTF) Transgénero de mujer a hombre (FTM) Otra identidad de género (especifique): __________ Prefiero no contestar (no lea esta respuesta en voz alta) [Aim to recruit at least three males per group and three females per group] ¿Cuál es el grado o año escolar más alto que ha completado? RECORD RESPONSE: Menos de preparatoria o diploma de equivalencia general (GED) Preparatoria o diploma de equivalencia general (GED) solamente Algo de universidad (sin título) Grado asociado completado u otro grado técnico de 2 años Licenciatura completa (pero no título de posgrado o profesional) Título de posgrado o profesional completado (maestría o superior) [Recruit at least one person that has HS degree or less]

Quotas for English and Spanish Groups

Prescription Medications	Currently taking prescription medicine- Include 5 to 7 per group	Currently not taking prescription medicine- Include no more than 2 individuals per group
Race/Ethnicity	Black/African American- Recruit at least 1 participant per group	Asian- Recruit at least 1 participant per group
Gender	Males- Recruit at least 3 per group	Females- Recruit at least 3 per group
Education	HS degree or less- At least 1participant per group

Gracias por su participación. Después de esta llamada, recibirá una declaración de participación por correo electrónico. Junto con esa declaración de participación se incluirán cuatro documentos en PDF, que nos gustaría que revisara antes de nuestra sesión por el Internet, así como algunas instrucciones sobre lo que debe tener en cuenta al leer los documentos. También le enviaremos por correo una copia de los materiales. Gracias.

Participant Screener (Tribal Groups)

The participant screener will take place over the phone:

Hello [NAME] We’re looking for people to participate in a 90-minute focus group in _______MONTH _______of YEAR. If you are interested, I will ask you a few questions to determine if you are eligible to participate.

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. If you are eligible to participate, you may take part in a focus group discussion with 5-8 people.

What is your age?	_______	If not between 55-74 (terminate) [50% of participants should be greater than or equal to be at least 60 yrs]
How would you describe your ability to get where you need to go on a typical day? For example, how easy is it for you to get around town? Would you say it is very good, good, fair, or poor?	☐ Very good (continue) ☐ Good (continue) ☐ Fair (continue) ☐ Poor (terminate)
Do you have high-speed internet access?	☐ Yes (continue)	☐ No (terminate)
Do you have a computer, tablet, or phone that you can use to participate in a virtual meeting?	☐ Yes (continue)	☐ No (terminate)
Does your internet access support online video conferencing through Zoom?	☐ Yes (continue) ☐ No (terminate) ☐ Don’t Know (terminate) [For tribal communities, if not enough individuals are familiar with Zoom, we may aid participants in using Zoom]
Do you have access to an active email account that you can use to receive notices about the study? This account is where we will send your confirmation email with important instructions on how to join the session.	☐ Yes (continue)	☐ No (terminate)
Do you currently take any prescription medicines for a health condition?	☐ Yes (Aim to include 5 to 7 individuals currently taking prescription medicines)	☐ No (Include no more than 2 individuals currently not taking prescription medicines)

Termination Language (if needed): Thank you for your time and for completing the screening process. Based on your responses, you are not eligible to participate in this project. We will contact you further if your responses seem to be a good match for future projects.

Based on your responses so far, you are eligible to participate in this project. If you agree to participate in this project, we will ask you to take part in a 90-minute online, video group discussion. During the session, you and 5-8 other people will take part in a group discussion. You will receive a $75 token of appreciation for your participation.

Are you willing to commit to a 90-minute online, video group discussion to participate in the project?	☐ Yes (continue)	☐ No (terminate)
The group discussion 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 (assign Tribal group)	☐ 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 Email Address City, State, Zip Confirm address for mailing letter and advance copy of MPP Resources
What Tribal group are you affiliated or identify with?	______________________________
(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? You may choose more than one [READ LIST:] American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, or White What sex were you assigned at birth, on your original birth certificate? Male Female Prefer not to answer (do not read this answer aloud) How do you describe your gender identity? Male Female Male-to-female transgender (MTF) Female-to-male transgender (FTM) Other gender identity (specify): ___________ Prefer not want to answer (do not read this answer aloud) [Aim to recruit at least three males per group and three females per group] 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) [Recruit at least one person that has HS degree or less]

Quotas for Tribal Group

Age	60+ yrs – At least 50% of participants per group
Prescription Medications	Currently taking prescription medicine- Include 5 to 7 per group	Currently not taking prescription medicine- Include no more than 2 individuals per group
Gender	Males- Recruit at least 3 per group	Females- Recruit at least 3 per group
Education	HS degree or less- At least 1 participant per group

Thank you for your participation. After this call, you will receive a statement of participation via email. Included with that statement of participation will be four PDF documents, which we would like you review before our online session, as well as some instructions on what to consider about them as read the documents. We will also mail you a copy of the materials. Thank You.