Form 1 Adolescent Recruitment Screener and Consent Form

OMB Number: 0925-0648

Expiration Date: 01/31/2015

Noisy Planet Mall Interviews

Adolescent Participant Recruitment Screener

Background

[The following is a guideline for the script that the interviewer will follow to capture an adolescent’s interest. It is not restricted to background information.]

We want your opinion. On behalf of the National Institutes of Health, a Federal agency, we are conducting brief interviews with adolescents to get their reactions to health education materials on hearing protection. The interviews will last 20 minutes. We are not selling or promoting any product or service. The responses will be kept secure to the extent permitted by law. We only need a first name. In the final report, your name will never be connected to any comment you made. There is no right or wrong answer.

To see if you qualify to participate in the interview, we need to ask you a few questions first. These questions will take less than 5 minutes. Do you have a couple minutes to see if you qualify?

ADOLESCENT Eligibility Questions

_____ Female

_____ Male

[Aim to recruit half boys and half girls, keeping in mind that the target racial/ethnic mix takes priority over gender.]

1. Are you between the ages of 8 and 12?

( ) Yes;

( ) No; THANK AND TERMINATE INTERVIEW [Keep count of the number of youth approached and terminated at this point.]

1a. What is your age? _____ years [Recruit a mix of ages.]

2. Are you comfortable reading AND speaking English?

( ) Yes

( ) No; THANK AND TERMINATE INTERVIEW

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

( ) Not Hispanic or Latino

( ) Hispanic or Latino

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

( ) African American or Black

( ) American Indian/Native American or Alaska Native

( ) Asian American/Asian

( ) Caucasian or White

( ) Native Hawaiian or Other Pacific Islander

INVITATION TO PARTICIPATE IN INTERVIEW SURVEY

Thank you for answering our questions. We would like to invite you to participate in an approximately 15-minute interview to hear your thoughts about some health education materials on hearing protection.

PARENTAL/GUARDIAN CONSENT FOR ADOLESCENT TO PARTICIPATE

I, _________________________, am the parent or guardian, age 18 or older, and give my permission for the minor named above to participate in an interview survey with 3Q Global.

Parent/Guardian Signature: __________________________ Date: ____________________

^{____________________________}

^ 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 Office of Management and Budget control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: National Institutes of Health, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0648). Do not return the completed form to this address.