New York State Department of Health
The Healthy Fishing Community Project in Syracuse, NY
August 7, 2014
Revised June 1, 2015
Readability, calculated using the Flesch-Kinkaid Readability Option in Microsoft Word, has been determined at the 6th grade level
Form Approved
OMB No. 0923-0052
Exp. Date 4/30/2017
Ask the participant these questions before beginning the interview.
Script: I’m going to ask you some questions about people you know in the City of Syracuse. Not including people you live with, think about how many adults (18 and older) you see and talk with regularly.
Of the people in the City of Syracuse you see and talk with regularly, about how many eat fish caught in the bodies of water that we talked about?
______ people ___ Don’t know ___ Refused
How many of these people would you consider referring to a project like this one?
______ people ___ Don’t know ___ Refused
If there are people you would not refer to this project, why would you not refer them? Read list of reasons.
Check all that apply.
___ [They already participated]
___ [They work so are unable to come to the events]
___ [I don’t know where they live]
___ Other Specify: __________________________________
___ Don’t know ___ Refused
If the participant is not a seed: What is your relationship to the person who gave you the coupon?
___ Friend or acquaintance
___ Co-worker
___ Store owner or employee
___ Other Specify: __________________________________
___ Don’t know ___ Refused
If the participant is not a seed: Would you have considered referring (name of recruiter), the person who referred you?
___ Yes ___ No ___ Don’t know ___ Refused
Public reporting burden of this collection of information is estimated to average 5 minutes per response for total participation, 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 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 Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0923-XXXX).
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | wdw0 |
File Modified | 0000-00-00 |
File Created | 2021-01-24 |