Formative - Developmental

OMB #: 0925-0593

Expiration Date: 07/31/2013

Participant Internet Usage and Contact Preference Survey, LOI2-INF-17

Recruitment Strategy Substudy

Event Name(s):

Participant Internet Usage and Contact Preference Survey

Instrument Name(s) and Versions:

Participant Internet Usage and Contact Preference Survey

– 1.0

Recruitment Groups:

Enhanced Household, Provider-Based, Low Intensity and High Intensity

Participant Internet Usage and Contact Preference Survey

TABLE OF CONTENTS

INTERVIEW 1

Participant Internet Usage and Contact Preference Survey

INTERVIEW

(TIME_STAMP_1) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

0001 What are the following ways you are able to participate in National Children’s Study data collection? SELECT ALL THAT APPLY.

TELEPHONE	………………………	1
Postal mail	………………………	2
email/internet/web	………………………	3
INTERVIEW WITH PROVIDER STAFF	………………………	4
REFUSED	………………………	-1
DON’T KNOW	………………………	-2

0002 INTERVIEWER INSTRUCTION: Do you usually prefer business contacts and acquaintances to contact you first via:

TELEPHONE	………………………	1
EMAIl	………………………	2
POSTAL MAIL	………………………	3
TEXT MESSAGING	………………………	4
APPOINTMENT/FACE TO FACE ONLY	………………………	5
REFUSED		-1
DON’T KNOW	………………………	-2

0003 We have a few questions about your familiarity and usage of internet (World Wide Web).

0004 Do you ever connect to the web/internet for either work or personal use?

YES	………………………………………	1
NO	………………………………………	2
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

0005 On average, how often do you use a web/internet browser?

MORE THAN 4 TIMES A DAY	………………………	1
1 TO 4 TIMES A DAY	………………………	2
A FEW TIMES A WEEK	………………………	3
oNCE A WEEK	………………………	4
once a month	………………………	5
REFUSED	………………………	-1
DON’T KNOW	………………………	-2

0006 Do you have an email address?

YES	………………………………………	1
NO	………………………………………	2
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

0007 If yes, how often would you say you log on to check your email?

1-5 TIMES A DAY	………………………	1
ONCE A DAY	………………………	2
1-3 TIMES A WEEK	………………………	3
lESS THAN ONCE A WEEK	………………………	4
ONCE EVERY 2 WEEKS	………………………	5
ONCE A MONTH	………………………	6
rARELY	………………………	7
NEVER	………………………	8
REFUSED	………………………	-1
DON’T KNOW	………………………	-2

0008 May we have your email address to contact you in the future?

ENTER E-MAIL ADDRESS: ___________________________________

REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

PROGRAMMER INSTRUCTION:THIS QUESTION WILL ONLY BE ASKED AFTER THE FIRST PN EVEN IS COMPLETED.

0009 In which way would you prefer to take this survey?

OVER THE PHONE	………………………………………	1
MAILED TO ME AND COMPLETED ON PAPER	………………………………………	2
EMAILED TO ME AND COMPLETED ONLINE	………………………………………	3
REFUSED	………………………………………	-1
DON’T KNOW	………………………………………	-2

*This question will only be asked after the first PN event is completed and will not be asked twice.

PROGRAMMER INSTRUCTION: FOR [DATA COLLECTION MODE] INSERT THE NAME OF THE TYPE OF DATA COLLECTION PARTICIPANT IS ASSIGNED TO RECEIVE. FOR [ALTERNATE DATA COLLECTION MODE 1] INSERT ONE OF THE REMAINING DATA COLLECTION MODES THE PARTICIPANT IS NOT ASSIGNED TO. FOR [ALTERNATE DATA COLLECTION MODE 2] INSERT THE REMAINING DATA COLLECTION MODE THE PARTICIPANT IS NOT ASSIGNED TO.

0010 Please provide some feedback about how this survey was completed. Tell us how much you agree or disagree with the following statements by responding with strongly disagree, somewhat disagree, somewhat agree or strongly agree.

	STRONGLY DISAGREE	SOMEWHAT DISAGREE	SOMEWHAT AGREE	STRONGLY AGREE
[DATA COLLECTION MODE] is simple to complete.	1	2	3	4
[DATA COLLECTION MODE] is convenient.	1	2	3	4
If I were given a choice, I would choose a [DATA COLLECTION MODE] over a [DATA COLLECTION MODE 1] or [DATA COLLECTION MODE 2].	1	2	3	4

(END) Thank you for taking the time to answer these questions, your answers are important to us. Your Research Coordinator will be in touch with you about your next Study event.

INTERVIEWER INSTRUCTION: THIS STATEMENT WILL BE USED FOR THOSE COMPLETING THE PN3 EVENT. You will receive a data collection mode survey again in about six months.

(TIME_STAMP_2) PROGRAMMER INSTRUCTION: INSERT DATE/TIME STAMP

Public reporting burden for this collection of information is estimated to average 5 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.