Form Screener

OMB No. 0930-0196

Expiration Date: 09/30/16

Public Burden Statement: 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. The OMB control number for this project is 0930-0196. Public reporting burden for this collection of information is estimated to average 5 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

ATTACHMENT A - SCREENING QUESTIONNAIRE FOR FOCUS GROUPS ON RECOVERY MONTH PSAS

Recruiter’s Name:______________________________________________________________________

Recruiter’s Organization:_________________________________________________________________

Recruiter’s Telephone/Mobile:____________________________________________________________

The purpose of these groups is to talk about some draft concepts for TV spots (called PSA) about recovery ….. As we begin the development of these products, we would like to hear from people who are in recovery of mental health or substance abuse, or are family members of people in recovery. The PSA is addressing the crucial role of receiving support throughout the recovery journey and how this support is helping to re-write people’s stories.

1. Are you interested in participating in this group session?

⃝ Yes ⃝ No [if No, terminate: “Thank you very much for your time. Have a good day/evening, goodbye”]

2. Are you available to participate in a 1.5 hours session during the week of: Dec 7 – 11/15 at evening hours?

⃝ [For WDC] Dec 7^th, 8^th, and 9^th ⃝ [For Atlanta (GA)] Dec 9^th, 10^th and 11^th [dates to be confirm]

⃝ Yes ⃝ No [if No, terminate “Based on your availability we cannot include you this time. Thank you for your interest.”]

Recruiter: I am going to ask you some questions that will indicate whether you qualify to participate in this discussion group.

3. Please let me know which one applies:

(Recruit 8 individuals in recovery for each location and a mix of at least three of the categories below)

⃝ I am the person in recovery

⃝ I am the parent of someone in recovery

⃝ I am the daughter/son of a parent/caregiver in recovery

⃝ I am a loved one/friend of someone in recovery

⃝ other, please explain

3. Are you in recovery from/the someone is in recovery from [recruit a mix at least of two of the following categories;]

⃝ Mental health

⃝ Substance abuse

⃝ Both

3. You or the person in recovery has been in recovery for how long [recruit a mix of at least two categories]

⃝ Within the past year

⃝ 1 to 3 years

⃝ 4 to 7 years

⃝ 8 years or more

3. Income [recruit a mix – wait for response]

⃝ Unemployed

⃝ $1,000 - $20,000

⃝ $21,000 - $45,000

⃝ $46,000 - $70,000

⃝ $71,000 - $100,000

⃝ $101,000 – 150,000

⃝ $151,000 – and above

3. Educational level [recruit a mix – wait for response]

⃝ Elementary School

⃝ Middle School

⃝ High School

⃝ Some college

⃝ College

3. Gender [attempt to recruit an equal number of male and female]

⃝ Female

⃝ Male

3. Are you of Hispanic or Latino origins? ⃝ Yes ⃝ No

4. What is your race? (Mark all that apply)- ⃝ American Indian or Alaska Native ⃝ Asian ⃝ Black or African American ⃝ Native Hawaiian or Other Pacific Islander ⃝ White

Recruiter: “Thank you for answering these questions. If you are selected as a group discussion participant, you will receive a call and an email to confirm your participation, and to be informed of the venue, date, and time of the group discussion session. Could you please provide us with information about the best way to contact you?”

Name: ___________________________________________________________________________

Email: _________________________________Phone/Mobile: _______________________________

Best time to be contacted: ____________________________________________________________

Recruiter: “Again, thank you for your collaboration. Goodbye”