Form #5 Form #5 Consumer or Patient Focus Group Screener Questionnaire

Attachment K

Consumer or Patient Focus Group Screener Questionnaire-Aware with Use

FOCUS GROUP SCREENING GUIDE: Consumers or Patients

Hello, my name is <insert name>. I am calling on behalf of IMPAQ International, a health care research and consulting firm in the Washington, DC area. We are calling to follow up with you regarding a survey you participated in x months ago, on behalf of the Agency for Healthcare Research and Quality (AHRQ). In the survey you indicated that you are aware of Patient Centered Outcomes Research (PCOR) and [select one of the three options] using it in your medical decisionmaking. not using it in your medical decision-making, or were not are aware of Patient Centered Outcomes Research (PCOR) We are working with AHRQ to talk to people about their experiences and awareness about scientific research that can help them and their family members make medical decisions.

At the end of the survey you indicated that you would be willing to participate in a telephone focus group. Are you still interested in participating in a 90 minute telephone focus group?

( ) Yes Continue

( ) No Thank and terminate

IF ASKED: (EACH INTERVIEWER WILL HAVE THIS INFORMATION).

If respondents ask how their name was obtained, tell them their phone number was randomly selected from a list of individuals who participated in the AHRQ sponsored survey conducted x months ago. These individuals were only chosen if they indicated that they would be willing to participate in a telephone focus group. If respondents are concerned about participating, tell them that our contract with the AHRQ specifically prohibits us from revealing anything more than their first name to the AHRQ or anyone else, and whether or not they participate in the focus group. Furthermore, their responses to the focus groups questions will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). Their name will not be used in any reports about this focus group and no quotes will be attributed to them.

This project has been approved by the U.S. Office of Management and Budget (OMB). The OMB Clearance Number is xxxx-xxxx. If you like, I can give you a name and address where you can send comments and questions or suggestions regarding the process for recruiting potential participants in the focus groups.

Agency for Healthcare Research and Quality

Address

Address

Your answers to these questions will be held in complete confidence by IMPAQ, meaning we will not provide anything more than your first name to the AHRQ. The incentive you will receive is in cash and is not reported as income to the IRS.

May I ask you a few questions to before we proceed?

( ) Yes Continue

( ) No Thank and terminate

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

( ) Yes Continue

( ) No Terminate

2. Are you familiar with Patient Centered Outcomes Research (PCOR)?

( ) Yes Continue

( ) No Terminate

2. Do you or does someone in your household work for AHRQ?

( ) Yes Terminate

( ) No Continue

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

( ) Yes Terminate

( ) No Continue

5. ¹Are you currently using PCOR or have you used PCOR to help you make medical decisions for yourself or a family member? Do not ask this question if he/she was not aware of Patient Centered Outcomes Research

( ) Yes Continue

( ) No Terminate

For questions 6-12, recruit a mix of individuals²

6. Are you a (check all that apply)

( ) Medicare beneficiary

( ) Medicaid beneficiary

( ) Private payer

( ) Recipient of VA or DoD benefits

( ) none of the above, please record other________

6. Are you a:

( ) Patient

( ) Caregiver

6. Do you or a does a close family member suffer with a chronic condition? (Examples are asthma, diabetes, etc.)

( ) Yes Continue

( ) No Continue

Please record the condition____________________________________________________

6. Into which of the following categories does your age fall? May opt-out if they wish to.

( ) less than 18 Terminate

( ) 18 to 33

( ) 34-44

( ) 45 to 64

( ) 65 and older

10. Please identify your highest completed level of education. [May opt-out if they wish to.]

( ) Some High School

( ) High School Diploma/GED

( ) Some College or Associate’s Degree

( ) Bachelor’s Degree

( ) Graduate or Professional Degree (M.D., J.D.)

11. Are you Hispanic or Latino/Latina?  

( ) Yes

( ) No

12. What is your race? Please select one or more.

( ) American Indian or Alaska Native

( ) Asian

( ) Native Hawaiian or other Pacific Islander

( ) Black or African American

( ) White

13. Record Gender—DO NOT ASK UNLESS UNABLE TO DETERMINE; may opt-out if they wish to.

( ) Female

( ) Male

INVITATION TEXT

Thank you for answering our questions. Based on your responses, we would like to invite you to participate in a telephone focus group which will be held on [insert date] at [insert time]. The total time will be no more than 90 minutes. We will provide everything that you need to participate in the focus group. Your participation is completely voluntary. We will provide you with a $75 stipend for participating.

Are you willing to participate?

( ) Yes Continue

( ) No Terminate

I’m glad that you will be able to join us! At this point I need to collect some contact information from you. Then we will send you a confirmation letter and toll free call in number that you will use for your participation .

§

We are only inviting a few people, so it is very important that you notify us as soon as possible if for some reason you are unable to participate. Please call [insert recruiter contact and phone] if this should happen. We look forward to having you participate on [insert day] at [insert time].

Do you have any questions?

Great! Thank you for your time and we will be in touch again on the day of the focus group.

TERMINATE TEXT

Thank you very much for your time, and thank you for answering our questions. Unfortunately, based on the focus group requirements, we cannot extend you an invitation. Perhaps at a later time we can include you in a focus group. Have a good [day/evening].

1 We deleted question 7, Are you aware that a CER x ran in your neighborhood recently?, because participates may be aware of PCOR through resources other than media campaign materials.

2 Once the subsegmentation criteria are decided upon with AHRQ, we will refine these.

5