Form #2 Form #2 Consumer or Patient Screener Questionnaire

Attachment C

Consumer or Patient Screener Questionnaire

Consumer or Patient Screener Questionnaire

Note: The sample frame for the consumer survey will include a nationally representative sample of 3,200 households that will be purchased from a sample vendor. Sampled households will be screened to identify eligible survey participants. The following script will be used to contact sampled households. Households that meet the eligibility requirements will be asked to complete the survey. Households that do not meet the eligibility requirements will be dropped from the survey sample.

Frequently asked questions and suggested answers follow the screener script. Interviewers will use this information as appropriate to answer questions and respond to concerns voiced by respondents or gatekeepers.

SOMEONE ANSWERS.............................................. 01  GO TO S1

ANSWERING MACHINE/VOICEMAIL....................... 02  GO TO S22

NO ANSWER…………………………………........................ 03  TERMINATE CALL. RECORD DISPOSITION.

S1. Hello, my name is [INTERVIEWER NAME] and I am calling from IMPAQ International on behalf of the Agency for Healthcare Research and Quality. May I speak to [RESPONDENT NAME]?

IF RESPONDENT ANSWERS THE PHONE AND CONFIRMS THEIR IDENTITY, GO TO S2.

IF SOMEONE ELSE ANSWERS THE PHONE, GO TO S11.

S2. We are conducting a short survey for the Agency for Healthcare Research and Quality. The purpose of the survey is to learn about your awareness of scientific research that may help you make medical decisions. The survey takes 15-20 minutes to complete. Are you willing to participate?

PROBE IF NECESSARY: You may have received a letter recently which explained the study to you.

YES, OK TO CONTINUE NOW....................... 01  GO TO S3

YES, BUT NOT A GOOD TIME ...................... 02  GO TO S10

NO, REFUSED............................................... 03  GO TO REFUSAL SCRIPTS.

S3. Thank you. Before we begin the survey, I need to ask a few questions to determine your eligibility.

CONTINUE TO S4

S4. Do you consider yourself to be fluent in English?

YES....................... 01  GO TO S5

NO........................ 02  Unfortunately you are not eligible for the survey. Thank you for

your time. TERMINATE.

S5. Do you or does someone in your household work for the Agency for Healthcare Research and Quality?

YES....................... 01  Unfortunately you are not eligible for the survey. Thank you for

your time. TERMINATE.

NO........................ 02  GO TO S6

S6. Are you a healthcare provider (i.e. physician, nurse, allied health worker) or work for a medical device or prescription drug company?

YES....................... 01  Unfortunately you are not eligible for the survey. Thank you for

your time. TERMINATE.

NO........................ 02  GO TO S7

S7. Have you visited a doctor or other health care professional in the past 12 months?

PROBE IF NECESSARY: This could include a doctor, nurse, physician assistant, or other type of health care professional.

YES....................... 01  GO TO S8

NO........................ 02  Unfortunately you are not eligible for the survey. Thank you for

your time. TERMINATE.

S8. Did this visit result in some kind of treatment?

YES....................... 01  GO TO S9

NO........................ 02  Unfortunately you are not eligible for the survey. Thank you for

your time. TERMINATE.

S9. Before we begin the survey, we must be sure that you clearly understand a few points. Your participation in the survey is completely voluntary. The Agency for Healthcare Research and Quality has obtained approval to conduct the survey from the federal government's Office of Management and Budget. All information you provide will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c), and your name will not be used in any summary reports. Your answers will not be shared with anyone outside of the Agency for Healthcare Research and Quality in any manner that would enable someone to identify you. You may refuse to answer any questions that you do not want to answer, and you may discontinue participation at any time. However, we hope that you will choose to answer as many questions as you can. This call may be monitored for quality assurance. May we begin?

RESPOND TO ANY QUESTIONS/CONCERNS AS NEEDED. REFER TO FREQUENTLY ASKED QUESTIONS AND ANSWERS.

YES............................................ 01  END OF SCREENER. BEGIN INTERVIEW.

NO, NOT A GOOD TIME............ 02  GO TO S10

NO, REFUSED............................ 03  Thank you for your time. TERMINATE.

S10. When would be a good time to call back and do the interview?

RECORD DATE OF CALLBACK APPOINTMENT:____________________

RECORD TIME OF CALLBACK APPOINTMENT:____________________

Thank you for your help. We look forward to speaking with you on <interview date> at <interview time. TERMINATE.

S11. We are trying to reach [RESPONDENT NAME] to conduct a brief survey on behalf of the Agency for Healthcare Research and Quality. May I speak with [RESPONDENT NAME]?

YES................................................. 01  GO TO S12

NO, NOT AVAILBLE........................ 02  GO TO S13

NO, REFUSING............................... 03  GO TO S15

NO, WRONG NUMBER.................. 04  GO TO S18

S12. WHEN RESPONDENT COMES TO THE PHONE: Hello, my name is [INTERVIEWER NAME] and I am calling from IMPAQ International on behalf of the Agency for Healthcare Research and Quality.

GO TO S2 AND PROCEED WITH SCREENER

S13. Do you know when we could reach him/her?

YES................................................. 01  GO TO S14

NO………………………......................... 02  GO TO S15

S14. When would that be?

RECORD DATE OF CALLBACK APPOINTMENT:____________________

RECORD TIME OF CALLBACK APPOINTMENT:____________________

Thank you for your help. TERMINATE.

S15. Can we call again to try to reach him/her? I can also leave our toll-free number with you so that he/she can call us. The toll-free number is 1-800-XXX-XXXX.

YES................................................. 01  Thank you for your help. PROVIDE TOLL-FREE NUMBER AND TERMINATE.

NO………………………......................... 02  GO TO S16

S16. May I leave a message with you for [RESPONDENT NAME]?

YES................................................. 01  GO TO S17

NO………………………......................... 02  I’m sorry if I inconvenienced you. Thank you for your time. TERMINATE.

S17. My name is [INTERVIEWER NAME] and I am calling from IMPAQ International on behalf of the Agency for Healthcare Research and Quality. I would like to conduct a brief interview with [RESPONDENT NAME] about his/her awareness of scientific research that may help him/her make medical decisions. The survey takes 15-20 minutes to complete, and he/she will be paid $10 for participating. Our toll-free number is 1-XXX-XXX-XXXX. Please ask [RESPONDENT NAME] to call us at a time that is convenient for him/her. Thank you.

S18. Do you know [RESPONDENT NAME]?

YES................................................. 01  GO TO S19

NO………………………......................... 02  I’m sorry if I inconvenienced you. Thank you for your time. TERMINATE.

S19. Do you have a telephone number for him/her?

YES................................................. 01  Thank you for your time. RECORD TELEPHONE NUMBER AND TERMINATE.

NO………………………......................... 02  GO TO S20

S20. Is there someone else I could call who might know his/her phone number?

YES................................................. 01  GO TO S21

NO………………………......................... 02  I’m sorry if I inconvenienced you. Thank you for your time. TERMINATE.

S21. RECORD NAME AND TELEPHONE NUMBER OF ALTERNATE CONTACT. ATTEMPT CONTACT AT LATER TIME.

S22. This message is for [RESPONDENT NAME]. My name is [INTERVIEWER NAME], and I’m calling from IMPAQ International on behalf of the Agency for Healthcare Research and Quality. We are trying to reach [RESPONDENT NAME] to complete a brief survey about his/her awareness of scientific research that may help him/her make medical decisions. He/she may have received a letter recently which explained the survey. The survey only takes 15-20 minutes to complete. Please call us toll-free at 1-XXX-XXX-XXXX to complete the survey. Anyone who answers our line will be able to talk to you about the survey.

We are open seven days a week. If you reach our voice mail, please leave a message that you are calling about the Agency for Healthcare Research and Quality survey and refer to Case Number <Respondent Case ID>. Also please clearly state your name and an area code and phone number where we can reach you. Thank you in advance for your participation.

TERMINATE CALL.

FREQUENTLY ASKED QUESTIONS AND ANSWERS

How did you get my name and telephone number?

We obtain names and phone numbers of potential survey participants through telephone directory listings.

What is the survey about?

The questions are about your awareness and use of scientific studies that can help you make medical decisions.

How long will this take?

On average it takes about 15 minutes to complete the survey. Depending on your experience, it could take more or less time.

Are my answers confidential?

A ny information you provide will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). Your answers will be combined with those of others and your name will never be used in reporting the results of the study. Your answer to questions will not affect your organization’s eligibility to receive future grant funding.

What happens if I don’t participate?

Your participation is completely voluntary. However, your experiences and opinions are very important to the success of the study.

I don’t have the time.

The survey is brief and should only take about 20 minutes of your time. You can complete the survey at a time that is convenient for you. The information that you provide is critical to the success of the study.

I’m not interested.

We’re interested in your opinions and experiences. There are no right or wrong answers. Any information you provide will be held in the strictest confidence.

Who do you work for?

I am calling from the IMPAQ International. IMPAQ is a non-profit research organization that does research for the Agency for Healthcare Research and Quality and other government agencies. We collect information for use in research and program evaluation projects. We are not selling anything and all of the information you provide will only be used for research purposes.

Will I be paid?

I am sorry, but we are not authorized to offer payment for your participation in this important research.

REFUSAL SCRIPTS

Too busy/no time now

I'm sorry to have caught you at a bad time. I would be happy to call back at a more convenient time. We have interviewers available morning, evening, and weekends and would be happy to schedule an appointment and have them call you then. When would be a good time for us to call back?

Tired or does not feel well

I am sorry to hear that. I would be happy to call back in a day or two, if that would be more convenient. When would be a good time for us to call back?

Not interested

The survey is part of the process to help the Agency for Healthcare Research and Quality learn how to let people know about its research that can help you make better medical decisions. This information is very important to the Agency for Healthcare Research and Quality.

I don’t want to set an appointment with you

Okay, I can leave our toll free telephone number with you. It is 1-800-XXX-XXXX. You can call us at a time that is best for you.

Confidentiality

Protecting people's privacy is important to us. We have policies and procedures to ensure that your answers are kept private and confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). Your name and contact information is stored in a computer database that is separate from the database that stores the answers to our questions. All of our computer files are password protected and stored on secure servers. In addition, all of our staff sign a confidentiality agreement as a condition of their employment. The information you provide is only used for the Agency for Healthcare Research and Quality.

Gatekeeper – not interested

We appreciate you sharing your opinions and trying to save our time, but I really do need to speak directly with [RESPONDENT NAME] even if he/she is not interested in doing the survey.

Gatekeeper - No time now

Could I leave our 1-800 number with you so that [RESPONDENT NAME] can call us to do the survey at his/her convenience. Our toll-free number is 1-800-XXX-XXXX.

Closing Scripts

Survey Completed

Thank you for your help doing the survey. We appreciate your time.

CONFIRM RESPONDENT PHONE NUMBER AND ADDRESS. UPDATE AS APPROPRIATE.

Partial Survey Completed

IF RESPONDENT CANNOT CONTINUE:

I understand you can't finish talking with me now. We would like to finish the survey at another time that is convenient for you. Can I set up an appointment to call you back?

YES................................................. 01  Thank you for your time today. GO TO APPOINTMENT SCREEN AND UPDATE RESPONDENT PHONE NUMBER FOR NEXT CONTACT

NO………………………......................... 02  GO TO CALL RESULTS AND RECORD DISPOSITION

IF YOU CANNOT CONTINUE BECAUSE OF TECHNICAL PROBLEMS:

I'm sorry, we are having problems with our computers today. Can I call back in a few minutes to finish the survey?

YES................................................. 01  Thank you for your time today. GO TO APPOINTMENT SCREEN AND UPDATE RESPONDENT PHONE NUMBER FOR NEXT CONTACT

NO………………………......................... 02  GO TO CALL RESULTS AND RECORD DISPOSITION

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