Radiation Dose Tool Feedback

Form Approved
OMB No. 0923-0047
Exp. Date 05/31/2016

ATTACHMENT C: Public Screening Instrument

Radiation Dose Tool

(Interview)

Summary Table

interview	Location	Date/Time	Audience
#1	Atlanta, Georgia	TBD	Public
#2	Atlanta, Georgia	TBD	Public
#3	Atlanta, Georgia	TBD	Public
#4	Atlanta, Georgia	TBD	Public
#5	Atlanta, Georgia	TBD	Public
#6	Atlanta, Georgia	TBD	Public
#7	Atlanta, Georgia	TBD	Public
#8	Atlanta, Georgia	TBD	Public
#9	Atlanta, Georgia	TBD	Public

Interview	Location	Date/Time	Audience
#1	Remote	TBD	Public
#2	Remote	TBD	Public
#3	Remote	TBD	Public
#4	Remote	TBD	Public
#5	Remote	TBD	Public
#6	Remote	TBD	Public
#7	Remote	TBD	Public
#8	Remote	TBD	Public
#9	Remote	TBD	Public

Recruit

• Recruit 9 public participants for interviews to be conducted in Atlanta, Georgia

• Recruit 9 public participants to be conducted remotely

Public

• Recruitment: Recruit 18 participants for onsite and remote interviews

• Incentive: $ 40 for each participant

• Duration: 60 minutes for each session

Good evening. My name is __________________ and I am calling from _______________, a market research firm. Today we are talking with people as part of a study for the Centers for Disease Control and Prevention. We are not selling anything. We have a few brief questions that will take just 10 minutes of your time, and if you qualify and are interested, we will invite you to take part in a discussion group with other people in your area that will take place at a later date.

[Terminate screener as soon as recruiting staff realizes the person does not speak or understand English]

1. In which of the following categories does your age fall?

01 under 18 years of age [THANK AND TERMINATE]

02 18-24 years of age

03 25-34 years of age

04 35-44 years of age

05 45-54 years of age

06 55-64 years of age

07 65-74 years of age

08 75 years of age or older

[DOCUMENT ON GRID]

[RECRUIT A MIX WITHIN EACH GROUP]

[RECRUIT SO THAT GROUPS TOGETHER ARE REFLECTIVE OF THE COMMUNITY]

2. Have you participated in a focus group, in-depth interview, telephone survey, and/or online survey in which you were asked your opinions regarding a product, a service, or advertising within the past six months?

01 Yes [THANK AND TERMINATE]

2. No

Public reporting burden of this collection of information is estimated to average 15 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0572).

2. Do you, or does any member of your household or immediate family work:

01 For a market research company

02 For an advertising agency or public relations firm

03 In the media (TV/radio/newspapers/magazines)

04 As a healthcare professional (doctor, nurse, pharmacist, dietician, etc.)

[IF YES TO ANY, THANK AND TERMINATE]

2. What is your current job title? What term would you use to describe your current profession? ________________________________________

[IF ANY OF THE FOLLOWING, THANK AND TERMINATE

• Employee of U.S. Department of Health and Human Services

• Employee of state or local health department

• Employee of Department of Homeland Security

• Employee of state or local emergency management agency

• Nuclear power plant employee, Radiation Safety Officer, health physicist or other radiation-related occupation

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

01 Grade school [THANK AND TERMINATE]

02 Less than high school graduate/some high school

03 High school graduate or completed GED

04 Some college or technical school

05 Received four-year college degree

06 Some post graduate studies

07 Received advanced degree

08 Other: _____________________

[DOCUMENT ON GRID]

[RECRUIT A MIX WITHIN EACH GROUP]

[RECRUIT SO THAT GROUPS TOGETHER ARE REFLECTIVE OF THE COMMUNITY]

FOR REMOTE INTERVIEWS (ASK QUESTIONS 6-8):

2. Do you use/access the internet?

1. Yes

2. No [IF NO, THANK AND TERMINATE]

2. Do you have internet access through which we can show you streaming video and images?

3. Yes

4. No [IF NO, THANK AND TERMINATE]

2. During the interview you will need to view a website. How will you be viewing the website?

5. Mobile/Smart Phone [THANK AND TERMINATE]

6. Tablet (i.e., Ipad, Samsung Galaxy, etc.)

7. Laptop or Desktop Computer

2. Gender

01 Male

02 Female

[DOCUMENT ON GRID]

[RECRUIT ABOUT A 50/50 MIX]

2. Please indicate your race or ethnic background. Are you?
   
   

Ethnicity:

a. ____ Hispanic or Latino (SKIP TO QUESTION 11)

b. ____ Not Hispanic or Latino

Race:

(One or more categories may be selected)

a. ____ White

b. ____ Black or African American

c. ____ American Indian or Alaska Native

d. ____ Native Hawaiian or Other Pacific Islander

e. ____ Asian

[RECRUIT A MIX]

[DOCUMENT ON GRID]

2. Number of children (under the age of 18) living in your household?

01 None

02 1-2 children

03 3-4 children

04 5 or more children

[DOCUMENT ON GRID]

[NOT A SCREENING CRITERION]

2. ASSESS AND VERIFY ABILITY TO SPEAK AND UNDERSTAND ENGLISH

Those are all of my questions. You do qualify for our discussion group and we would like to invite you to join us on _______ at ______ PM. The discussion will last about 60 minutes; it will be recorded (audio only) to be sure we get all the information. In appreciation for your time, you will be given $40 at the time of the discussion.

Are you willing to participate?

01 yes

02 no

Prior to the start of the group discussion, you will receive an information sheet with such information as sponsorship of the study and contacts for more information. If after we hang up, you have a question about this group discussion or decide you can’t participate, please contact me at ________________.

Name_________________________________________________________________

Address________________________________________________________________

City/State/Zip___________________________________________________________

Day Number_________________________Night Number_____________________