Form Screening Question Screening Question Screening Questionnaire

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, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland 20857.

SCREENING QUESTIONNAIRE FOR FOCUS GROUPS

RECOVERY MONTH PSAs

Recruiter’s Name: _______________________________________________________________

Recruiter’s Organization: _________________________________________________________

Recruiter’s Telephone/Mobile: ____________________________________________________

Hello. My name is ___________________. I work at _____ (organization’s name). We are interested in taking with ________. We are beginning the development of some TV spots about recovery¹, and would like your opinion about some concepts for TV/radio spots (called PSA). We would like to hear from people who are in recovery of mental health or substance abuse, or are family members or friends of people in recovery. The PSA that we have in mind will encourage communities to be socially inclusive of people in recovery, as social connections improve the process for people with behavioral health conditions. People in recovery want to participate in their communities through meaningful daily activities—such as work, volunteerism, family caretaking, or creative endeavors—and want opportunities for independence, income, and resources to engage in society.

[RECRUIT 12 individuals for a SHOW of 10)

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 2.0 hours session during the week of: October 2016 at evening hours?

⃝ [Rockville] Oct [TBA]^. ⃝ [Ft. Lauderdale/Tampa, FL] Oct [TBA] [dates to be confirm]

⃝ Yes [continue]

⃝ 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 10 individuals for each location and a mix of at least three of the categories below)

⃝ I am a person in recovery

⃝ I am a family member/caregiver, loved one/friend of someone in recovery

⃝ I am a provider working on a CBOs, NGOs, faith organization, or drug courts² servicing people in recovery and/or their families

⃝ other, please explain

4. Are you in recovery from/the someone is in recovery from; organization is servicing individual and families recovering from [recruit a mix categories;]

⃝ Mental health

⃝ Substance abuse

⃝ Both

5. Age [recruit a mix – wait for response]

⃝ 18–28

⃝ 29–39

⃝ 40–50

⃝ 51–60

⃝ 61+

6. 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

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

⃝ Elementary School

⃝ Middle School

⃝ High School

⃝ Some college

⃝ College

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

⃝ Female

⃝ Male

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

10. What is your race? Select all that apply. [Do not read, wait for the response.]

⃝ American Indian/Alaska Native

⃝ Asian

⃝ Black/African American

⃝ Native Hawaiian/Other Pacific Islander

⃝ White

11. Please select which option describes you best. [Recruit equal number of Spanish dominant and English dominant individuals to participate in the appropriate groups]

⃝ I only speak Spanish.

⃝ I am a Spanish-dominant speaker.

⃝ I am bilingual in English and Spanish.

⃝ I am an English-dominant speaker.

⃝ I only speak English.

Recruiter: “Thank you for answering these questions. If you are selected as a group discussion participant, you will receive a call/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”

RECRUITMENT FOR RECOVERY MONTH FGs

PARTICIPANTS SELECTION CRITERIA:

• Recruit a mix of individuals in recovery, including recovery from substance abuse, mental health and co-occurring disorders (both).

• Recruit a mix of family members, loved one/friend of someone in recovery.

• Recruit a mix of providers of CBOs, NGOs, faith organizations, or drug courts that are servicing people in recovery and/or their families

• Recruit equal number of men and women in recovery

• Recruit a mix of ages from 18 to 65 years olds

• Recruit a mix of income levels

• Recruit a mix of educational levels

• Recruit a mix of Spanish dominant participants from different countries of origin (attempt a mix of different countries)

PARTICIPANTS’ DESIRED DISTRIBUTION –

	FG 1/ MD ENGLISH	FG 2/MD SPANISH	FG 3/FL ENGLISH	FG 4/FL SPANISH	TOTAL
# of participants	10	10	10	10	40
Gender
Female	5	5	5	5	20
Male	5	5	5	5	20
Ages
18–28	2	2	2	2	8
29–39	2	2	2	2	8
40–50	2	2	2	2	8
51–60	2	2	2	2	8
61 +	2	2	2	2	8
Categories
Individuals in recovery	3	3	3	3	12
Family members, loved ones friends of someone in recovery	4	4	4	4	16
Providers of CBOs, NGOs, faith org/s or drug courts	3	3	3	3	12
Ethnicity/Race	Attempt a mix of ethnic/racial groups. For Hispanic/Latinos attempt a mix of countries of Origin				40
Education/income	Attempt a mix of educational and income levels				40

1 SAMHSA defines recovery as a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential.

2 In Drug Court, Judges, Prosecutors, Defense Attorneys, Case Managers, Law Enforcement, Probation & Parole Officers, CPS Case Workers, and Treatment Providers review every individual case and work together.

ATTACHMENT A – Screening and Recruiting Questionnaire