DHQP Interview Screener

WS-CDC DHQP Interview Screener

Form Approved

OMB Control No.: 0920-1154

Expiration date: 03/31/2026

Antimicrobial Resistance Communications and Media Support Services

Division of Healthcare Quality Promotion (DHQP)

Screener for Long-Term Care Facility (LTCF) Resident and Family Interviews

March 25, 2025 Final

Introduction

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

You indicated that you are interested in participating in a virtual one-on-one interview, to discuss your experiences and opinions regarding a health topic. [DO NOT DISCLOSE THE EXACT TOPIC OF DISCUSSION BEFORE THE INTERVIEW.] This activity is supported by the U.S. Centers for Disease Control and Prevention and interviews are being conducted by their contractual partner KRC Research.

I have a few questions to start. But first, to maintain participants’ confidentiality, we will use first names only during the interview and your name will not be used in any study materials. CDC will not receive any personally identifying information that you provide. We will be asking you a few questions to ensure we are recruiting a variety of people, but the information will not be associated with your specific name.

IF TERMINATED DURING SCREENING PROCESS: READ: “I’M SORRY, WE ALREADY HAVE ENOUGH INDIVIDUALS IN THAT CATEGORY. THANK YOU VERY MUCH FOR YOUR TIME.”

IF INDIVIDUAL EXPRESSES CONCERN DURING SCREENING: NOTE CONCERN AND REASSURE APPROPRIATELY. REMIND THAT PARTICIPATION IS VOLUNTARY, AND ANSWERS AND PARTICIPATION ARE 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

Fifteen to eighteen long-term care facility (LTCF) residents and their family member/friend will be recruited for paired interviews. Each interview will include one paired interview with a LTCF resident and their family member/friend together (45 minutes) and a 15-minute follow-up interview for just the family member/friend (15 minutes). The LTCF resident will be recruited through their family member or friend who will be responding to the screening questions outlined below.

Below is a summary of core qualifications. All other quotas and exclusions in the screener also apply.

LTCF Resident	Family or Friend
Recruit 15-18	Recruit 15-18
Resides only in a nursing home or skilled nursing facility Does not reside in a dedicated memory care unit within a LTCF Consents to having a family member/friend present during the conversation	Regularly visits and engages with the resident Participates in conversations with the resident about healthcare decisions Does not currently or has not previously worked in a healthcare setting or public health department Has not participated in more than one research interview or focus group in the last six months Consents to having their resident loved one present during the conversation

Screening Questions

1. 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	CONTINUE
2 or more	THANK AND TERMINATE

1. What city and state do you live in? RECORD. [RECRUIT A MIX OF REGIONS ACROSS INTERVIEWS]

3. What is your sex?

Female		RECRUIT A MIX
Male

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

17 or younger		THANK AND TERMINATE
18 or older		CONTINUE

5. Do you have a family member or close friend that resides full-time in either a nursing home or skilled nursing facility? If so, which type of facility?

Yes, nursing home		CONTINUE
Yes, skilled nursing facility		CONTINUE
No		THANK AND TERMINATE

6. How is this resident of a long-term care facility related to you?

The resident is your…

Parent (mother or father)		CONTINUE
Grandparent (grandmother or grandfather)
Child (son or daughter)
Other family member (aunt, uncle, cousin, etc.)
Close friend, not related

Do you believe this loved one would be interested in participating in this interview with you and a member of the project team?

Yes		CONTINUE
No		THANK AND TERMINATE

7. This activity involves a joint 45-minute interview that will require you and your loved one to be present in the same location together. You will need to find a time that works for you both to participate from a quiet, private location. The activity will involve a video call between you both and the interviewer. Instructions will be provided, but you will be expected to supply a video-connected computer or tablet and manage the logistics of the connection for you and your loved one. Afterward, you alone will be asked to participate in a 15-minute follow-up interview at a convenient time.

Do you think you and your loved one would be willing and able to participate in this activity?

Yes		CONTINUE
No		THANK AND TERMINATE

Now, I am going to ask you some more questions about your loved one who resides in a long-term care facility.

8. Does this loved one reside in a dedicated memory care unit within their long-term care facility?

Yes		THANK AND TERMINATE
No		CONTINUE

9. In what city and state is the facility located? RECORD.

10. How frequently do you visit your loved one at their long-term care facility?

Daily		CONTINUE
A few times a week
Three or more times a month
One or two times a month		TERMINATE
Less than once a month

11. In the past several months, have you participated in conversations about health needs and health decisions with your loved one in this facility?

Yes		CONTINUE
No		TERMINATE

12. Approximately how long has your loved one been residing full-time in their current long-term care facility? [RECORD PRECISE ANSWER, AND ALSO CODE TO BELOW]

1-29 days		TERMINATE
30-60 days		RECRUIT A MIX
61-99 days
100 days or more

13. Have you or your loved one residing in the long-term care facility ever worked in a healthcare setting, public health department, or another health-related role? Select all that apply.

Yes, I currently/previously worked in a healthcare setting, public health department, or health-related role		TERMINATE
Yes, my loved one currently/previously worked in a healthcare setting, public health department, or health-related role
No, neither me nor my loved one have worked in a healthcare setting or public health department		CONTINUE

14. To the best of your knowledge, approximately how many residents are there at your loved one’s long-term care facility? [RECORD PRECISE ANSWER, AND ALSO CODE TO BELOW]

Small: 1-29 residents		RECRUIT A MIX
Medium: 30-99 residents
Large: 100 or more residents

Finally, a few questions to help us better understand your loved one who is residing at a long-term care facility. Please answer these to the best of your ability.

15. What is their sex?

Female		CONTINUE
Male

16. What is their age? RECORD.

17. What is their level of mobility? I will read four options.

Cannot leave bed independently		CONTINUE
Able to move from bed to other adjacent surfaces, like a chair, but cannot otherwise get around independently
Able to get around independently with a wheelchair
Able to get around independently with a walker, cane, or no support

18. For contextual purposes only, does your loved one have any wounds? [NOT REQUIRED TO BE SPECIFIED; DO NOT READ ANSWER CHOICES]

Yes		CONTINUE
No
Prefer not to say

For contextual purposes only, does your loved one have any medical devices that connect from the inside of their body to the outside, like a urinary catheter, feeding tube, or tracheostomy "breathing" tube? [NOT REQUIRED TO BE SPECIFIED; DO NOT READ ANSWER CHOICES]

Yes		CONTINUE
No
Prefer not to say

19. For contextual purposes only, has your loved one been placed in isolation at their long-term care facility in the past? [NOT REQUIRED TO BE SPECIFIED; DO NOT READ ANSWER CHOICES]

Yes		CONTINUE
No
Prefer not to say

Invitation

Thank you for answering all my questions. We respect your privacy and understand this information is confidential, and we will not disclose this information to anyone. We asked these questions because we want to speak with a variety of people who can provide their opinions and experiences. Based on your answers, we would like to invite you and your loved one who resides in a long-term care facility to participate in an interview activity. I will share some information and ask you if you are capable and interested in participating under the terms.

First, as stated previously, this activity involves a joint 45-minute interview that will require you and your loved one to be present in the same location together. You will need to find a time that works for you both to participate from a quiet, private location. The activity will involve a video call between you both and the interviewer. Instructions will be provided, but you will be expected to supply a video-connected computer or tablet and manage the logistics of the connection for you and your loved one. We request that you do not participate using a cell phone, so that the screen is large enough for the interviewer to see you both, and vice versa.

Second, as stated previously, you alone will be asked to participate in a 15-minute follow-up interview at a convenient time.

All interviews will be confidential and never be reported in association with personally identifying details like your names. To make sure we capture your remarks accurately, we will audio and video record the interviews. The purpose of the recording is to make sure we report accurately.

You and your loved one will both receive $75 as a token of appreciation for your participation, which will be provided to you both after completing the discussion.

After learning this information, is this something you are interested in and comfortable with?

Yes		CONTINUE
No		THANK AND TERMINATE

CONFIRM DATE AND TIME OF INTERVIEW WITH LOVED ONE RESIDING IN A LONG-TERM CARE FACILITY

CONFIRM DATE AND TIME OF 15-MIN FOLLOW-UP

Please provide the best telephone number to reach you:

RECORD PHONE NUMBER

Please indicate how you would like us to confirm with you:

PHONE OR EMAIL, RECORD EMAIL IF PREFERENCE

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

Public reporting burden of this collection of information is estimated to average 10 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