Form 6 Recruitment Screener Mom telephone focus group

OMB Number: 0925-0643

Expiration Date: 10/31/2014

Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)

National Child and Maternal Health Education Program (NCMHEP)

Understanding Perceptions of

Postpartum Depression

To Inform Educational Outreach Efforts

--Focus groups with mothers with at least 1 child less than 5 years of age--

RECRUITMENT SCREENER:

4 60-MINUTE TELEPHONE FOCUS GROUPS

Background

We are conducting a telephone focus group with mothers to talk about moms’ and children’s health shortly after birth. We are not selling or promoting any product or service. Everyone who participates in the focus group will receive $20 as a token of appreciation for your time. The telephone focus group will last 60 minutes. The discussion will be audio-recorded and kept secure to the extent permitted by law. First names only will be used during the discussion. In the final summary report, your individual name will never be connected to a comment you make during the discussion. To see if you qualify to participate in the focus group discussion, we need to ask you a few questions. These questions will take less than 5 minutes.

Eligibility Questions

RECRUIT 12 TOTAL PARTICIPANTS FOR EACH FOCUS GROUP (9 PARTICIPANTS WILL BE SEATED; ALL PARTICIPANTS WHO SHOW, EVEN THOSE WHO ARE EXCUSED, WILL RECEIVE THE INCENTIVE).

Confirm that the individual speaks English clearly. _____

1. Are you a mother of at least 1 child less than 5 years of age?

( ) Yes

( ) No THANK AND TERMINATE

2. Have you ever been diagnosed with postpartum depression by a health care professional?

( ) Yes THANK AND TERMINATE [CONSIDER RECRUITING FOR THE POSTPARTUM DEPRESSION MOTHER GROUPS]

( ) No

3. What is your age? _____ years

4. What is your city and state? ________________

RECRUIT A MIX OF GEOGRAPHIC LOCATIONS.

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

( ) Some high school

( ) Completed high school

( ) Some college/university

( ) Some technical school

( ) Completed college/university/technical school

( ) Any advanced degree

If yes to advanced degree, ask which field the respondent earned the degree in.

[SCREEN OUT PHYSICIANS (MEDICAL DOCTORS), NURSE PRACTITIONERS (NPs), NURSES, AND MENTAL HEALTH PROFESSIONALS]

6. Which of the following categories best describes your ethnic background?      

(     ) Not Hispanic or Latino

(     ) Hispanic or Latino

___ Mexican, Mexican American, Chicano/a

___ Puerto Rican

___ Cuban

___ Another Hispanic, Latino/a or Spanish Origin

7. Which of the following categories best describes your racial background?

(     ) White.......................................................................................Terminate

(     ) Black or African American......................................................Continue

(    ) American Indian or Alaska Native...........................................Continue

(     ) Asian………….........................................................................Continue

___ Asian Indian

___ Chinese

___ Filipino

___ Japanese

___ Korean

___ Vietnamese

___ Other Asian

(     ) Native Hawaiian or Other Pacific Islander …………………Terminate

ONE FOCUS GROUP WILL BE COMPOSED ENTIRELY OF AFRICAN AMERICAN MOTHERS

A 2^nd FOCUS GROUP WILL BE COMPOSED ENTIRELY OF ASIAN/ASIAN AMERICAN MOTHERS

A 3^rd FOCUS GROUP WILL BE COMPOSED ENTIRELY OF ENGLISH-SPEAKING HISPANIC/LATINA MOTHERS

A 4^TH FOCUS GROUP WILL BE COMPOSED ENTIRELY OF AMERICAN INDIAN OR ALASKA NATIVE MOTHERS

8. How well do you agree with this statement?

“I can really talk about my feelings with my significant other.”      

(     ) Strongly agree

(     ) Agree

(     ) Slightly agree

(     ) Slightly disagree

(     ) Disagree

(     ) Strongly Disagree

9. How well do you agree with this statement?

“I can really talk about my feelings with my family.”      

(     ) Strongly agree

(     ) Agree

(     ) Slightly agree

(     ) Slightly disagree

(     ) Disagree

(     ) Strongly Disagree

10. How well do you agree with this statement?

“I can really talk about my feelings with my friends.”      

(     ) Strongly agree

(     ) Agree

(     ) Slightly agree

(     ) Slightly disagree

(     ) Disagree

(     ) Strongly Disagree

11. What was your total household income before taxes during the past 12 months?

(     ) Less than $25,000

(     ) $25,000 to $34,999

(     ) $35,000 to $49,999

(     ) $50,000 to $74,999

(     ) $75,000 to $99,999

(     ) $100,000 to $149,999

(     ) $150,000 or more

[Use the following language when terminating a call:
“Thank you very much for your time today. We are looking to recruit a wide variety of women from across the United States to help with this study. Unfortunately, we have filled participant slots with your specific characteristics. Again, thank you for your interest.”]

INVITATION

Thank you for answering our questions. We would like to invite you to participate in a 1-hour telephone focus group discussion with other mothers to hear your thoughts on moms’ and children’s health shortly after birth. If you agree to participate you will receive $20 as a token of appreciation for your time.

• Are you interested and able to participate?

( ) Yes SCHEDULE

( ) No THANK AND TERMINATE

FOR SCHEDULED PARTICIPANTS:

We will send you a confirmation email, with the call-in instructions, before your telephone focus group discussion. And, we will call you the day before the telephone focus group discussion as a reminder. Please call into the call-in number at least 5 minutes before the start of your focus group.

Name_________________________________________________________________

Address_______________________________________________________________

City/State/Zip Code_______________________________________________________

Home___________________ Work _______________ Cell ____________________

Email ­­­­­­­­­­­­­­­___________________________________________________________

What is the best telephone number to reach you? ________________________

Thank you!

Public reporting burden for this collection of information is estimated to average 5 minutes, 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0532). Do not return the completed form to this address.