Form 1 Claimant Screener Survey 1

OMB
 No.:
 0925-­‐XXXX

Expiration
 Date:
 XX/XX/2017

Survey
 1
 –
 Claimant
 Screener

S1.

Hello,
 may
 I
 speak
 with
 (CLAIMANT
 (IF
 NEEDED:
 I
 am
 trying
 to
 reach
 the
 person
 who
 recently

received
 a
 letter
 from
 the
 SSA
 about
 a
 research
 study))?

[IF
 ASKED,
 “WHO’S
 CALLING?”]:

My
 name
 is
 (DATA
 COLLECTOR)
 and
 I
 am
 calling
 from
 Westat
 about
 a
 Social
 Security

Administration
 research
 study.

YES/SPEAKING
 ......................................................

  1

NOT
 AVAILABLE
 ....................................................

  2

(GO
 TO
 INTRO1)

(SET
 CALLBACK)

[INTRO1]

Hello,
 this
 is
 (INTERVIEWER)
 and
 I’m
 calling
 from
 Westat
 about
 a
 Social
 Security
 Administration
 (SSA)

research
 study.

 The
 National
 Institutes
 of
 Health
 and
 Boston
 University
 are
 doing
 this
 study
 and
 Westat

is
 supporting
 them.

 We
 recently
 sent
 you
 a
 letter
 about
 the
 study.

 I
 am
 calling
 now
 to
 invite
 you
 to

participate
 in
 the
 study.

Before
 we
 get
 started,
 I
 am
 required
 to
 read
 to
 you
 a
 statement
 from
 the
 Office
 of
 Management
 and

Budget
 (the
 OMB).

 This
 statement
 will
 provide
 you
 with
 contact
 information
 should
 you
 have
 questions

or
 comments
 about
 the
 amount
 of
 time
 this
 study
 will
 take.

OMB
 No.:
 0925-­‐XXXX

Expiration
 Date:
 XX/XX/2017

Public
 reporting
 burden
 for
 this
 collection
 of
 information
 is
 estimated
 to
 average
 3-­‐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
  aspects
  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-­‐XXXX).

I
 appreciate
 for
 your
 patience
 as
 I
 read
 that.

S2.

First,
 are
 you
 age
 21
 or
 older?

YES
 .......................................................................

NO
 ........................................................................

REFUSE
 .................................................................

DON’T
 KNOW
 .......................................................

1

2

7

8

(GO
 TO
 S3)

(GO
 TO
 THANK1)

(GO
 TO
 THANK1)

(GO
 TO
 THANK1)

1

Version
 6

6/26/14

S3.

You
 recently
 filed
 an
 application
 for
 work
 disability
 with
 the
 Social
 Security
 Administration,
 is

that
 correct?

YES
 .......................................................................

NO
 ........................................................................

REFUSE
 .................................................................

DON’T
 KNOW
 .......................................................

1

2

7

8

(GO
 TO
 INTRO2)

(GO
 TO
 THANK1)

(GO
 TO
 THANK1)

(GO
 TO
 THANK1)

[INTRO2]

Now,
 I
 would
 like
 to
 explain
 to
 you
 a
 little
 more
 about
 taking
 part
 in
 the
 study.

 Please
 listen
 carefully.

 I

will
 be
 asking
 you
 a
 few
 questions
 afterwards
 to
 make
 sure
 you
 understand.

First,
 your
 decision
 to
 take
 part
 in
 the
 study
 is
 voluntary
 and
 completely
 up
 to
 you.

 We
 randomly
 chose

you
 from
 a
 large
 group
 of
 people
 who
 applied
 for
 social
 security
 disability
 benefits
 in
 the
 last
 couple
 of

months.

 However,
 this
 study
 has
 nothing
 to
 do
 with
 your
 disability
 claim
 and
 your
 claim
 will
 not
 be

affected
 by
 your
 decision
 to
 take
 part
 in
 the
 study.

 SSA
 staff
 involved
 in
 the
 disability
 determination

process
 will
 not
 even
 know
 if
 you
 take
 part
 in
 this
 study.

 We
 will
 ask
 you
 to
 complete
 2
 surveys.
 Survey

1
 can
 be
 completed
 during
 this
 call
 or
 at
 later
 time
 convenient
 to
 you.

 You
 may
 decide
 to
 do
 Survey
 1
 on

your
 own
 over
 the
 internet
 or
 with
 me
 on
 the
 telephone.

 After
 you
 complete
 Survey
 1,
 you
 will
 receive

a
 check
 for
 $20
 for
 your
 time.

 We
 will
 call
 you
 about
 10
 days
 after
 you
 finish
 Survey
 1
 to
 invite
 you
 to

complete
 Survey
 2.
 You
 may
 also
 decide
 to
 do
 Survey
 2
 on
 your
 own
 over
 the
 internet
 or
 with
 an

interviewer
 on
 the
 telephone.

 After
 you
 complete
 Survey
 2,
 you
 will
 receive
 an
 additional
 check
 for
 $30

for
 your
 time.

I
 also
 need
 to
 tell
 you
 about
 some
 possible
 risks,
 if
 you
 decide
 to
 take
 part
 in
 the
 study.

 First,
 it
 is

possible
 that
 some
 of
 the
 questions
 we
 ask
 may
 upset
 you.

 We
 are
 asking
 questions
 about
 your

functioning
 (activities)
 and
 you
 might
 find
 some
 of
 those
 embarrassing
 or
 they
 may
 hurt
 your

feelings.

 You
 do
 not
 have
 to
 answer
 any
 question
 that
 you
 do
 not
 want
 to
 answer,
 and
 you
 can
 stop

answering
 questions
 at
 any
 time.

 In
 addition,
 we
 will
 keep
 your
 contact
 information,
 such
 as
 your
 name,

address,
 phone
 number
 and
 email
 address
 secure
 to
 the
 fullest
 extent
 of
 the
 law.

 However,
 there
 is

always
 a
 small
 risk
 of
 loss
 of
 privacy.
 We
 go
 to
 great
 lengths
 to
 keep
 your
 information
 private.

 Finally,

there
 is
 little
 physical
 risk
 involved
 with
 taking
 part
 in
 this
 study.

 However,
 answering
 the
 questions

could
 make
 you
 tired.

Now,
 I
 would
 like
 to
 ask
 just
 a
 few
 questions
 to
 see
 if
 you
 can
 take
 part
 in
 the
 study.

S4.

What
 is
 1
 potential
 risk
 of
 participating
 in
 this
 study?

(NOTE
 TO
 INTERVIEWER:
 RESPONDENT
 MUST
 BE
 ABLE
 TO
 PROVIDE
 1
 OF
 THE
 POSSIBLE
 RESPONSES

BELOW.)

Possible
 Responses:

2

Version
 6

6/26/14

•
•
•
•
•
•
•
•
•

The
 questions
 might
 make
 me
 upset
 (please
 accept
 any
 synonym
 for
 this,
 including
 but
 not

limited
 to:
 sad;
 cry;
 mad;
 angry;
 unhappy)

The
 study
 won’t
 affect
 my
 current
 disability
 application/claim
 for
 benefits

Someone/SSA
 might
 find
 out
 who
 I
 am

Someone/SSA
 might
 know
 my
 answers
 came
 from
 me

My
 information
 might
 get
 lost

The
 information
 I
 give
 may
 not
 be
 kept
 secure/private/secret

Someone
 might
 hack
 into
 my
 information

I
 may
 get
 tired/sleepy/exhausted/drained/worn
 out

Little
 risk
 for
 physical
 discomfort/distress/concern/pain

ACCURATE
 ANSWER
 ................................

  1

INACCURATE
 ANSWER
 ............................

  2

REFUSE
 .......................................................
 7
 (GO
 TO
 THANK1)

DON’T
 KNOW
 .............................................
 8
 (GO
 TO
 THANK1)

S5.

Name
 1
 thing
 you
 will
 do
 in
 this
 study?

(NOTE
 TO
 INTERVIEWER:
 RESPONDENT
 MUST
 BE
 ABLE
 TO
 PROVIDE
 1
 OF
 THE
 POSSIBLE
 RESPONSES

BELOW.)

Possible
 Responses:

• I
 will
 do
 a
 survey

• I
 will
 do
 2
 surveys
 /
 I
 will
 answer
 questions
 2
 times
 (contact
 frequency)
 [THIS
 SHOULD
 BE

COUNTED
 AS
 A
 COMPLETE
 CORRECT
 RESPONSE.]

• I
 will
 take
 one
 survey
 now
 (contact
 frequency)

• I
 will
 take
 the
 next
 survey
 in
 10
 days
 (contact
 frequency)

• I
 will
 answer
 questions
 about
 my
 functioning/how
 I
 do
 things/my
 activities
 (survey
 content).

• I
 will
 take
 the
 survey/answer
 questions
 over
 the
 internet/on-­‐line
 by
 myself
 (administration

mode).

• I
 will
 take
 the
 survey/answer
 questions
 with
 interviewer
 over
 the
 telephone
 (administration

mode).

ACCURATE
 ANSWER
 ................................

  1

INACCURATE
 ANSWER
 ............................

  2

REFUSE
 .......................................................
 7
 (GO
 TO
 THANK1)

DON’T
 KNOW
 .............................................
 8
 (GO
 TO
 THANK1)

BOX
 1

IF
 RESPONDENT
 CORRECTLY
 DESCRIBES
 1
 RISK
 AND

1
 ELEMENT
 OF
 PARTICIPATION
 (S4=
 1
 AND
 S5
 =
 1),
 THEN
 GO
 TO
 S6.

OTHERWISE,
 GO
 TO
 THANK1.

3

Version
 6

6/26/14

S6.

What
 are
 the
 names
 of
 the
 conditions
 you
 would
 say
 are
 the
 main
 reasons
 why
 working
 is

difficult
 for
 you?
 [LIST
 UP
 TO
 3
 ONLY]

a.______________________________________

b.______________________________________

c.______________________________________

REFUSE
 ..................................................................
 7

DON’T
 KNOW
 ........................................................
 8

S7.

CLAIMANT
 CONSENT:

 Let
 me
 review
 the
 consent
 form
 that
 we
 sent
 to
 you
 in
 the
 mail:

Please
 remember
 that
 it
 is
 your
 choice
 whether
 to
 participate
 in
 this
 study.

 You
 can
 skip
 any

questions
 that
 you
 do
 not
 want
 to
 answer.

 This
 study
 is
 not
 related
 to
 your
 application
 for

benefits
 and
 whether
 or
 not
 you
 participate
 will
 not
 affect
 your
 current
 or
 any
 future

application.

 If
 you
 do
 participate,
 please
 realize
 that
 you
 do
 not
 give
 up
 any
 of
 your
 legal

rights.

 If
 you
 withdraw
 from
 the
 study
 at
 any
 time
 it
 will
 not
 affect
 you
 in
 any
 way.

 Nothing
 in

the
 study
 will
 directly
 benefit
 you.

 Hopefully,
 it
 will
 benefit
 future
 applicants.

Both
 Survey
 1
 and

 2
 will
 take
 about
 45
 minutes
 to
 complete.

 You
 may
 obtain
 further

information
 about
 your
 rights
 as
 a
 research
 participant
 by
 calling
 the
 Office
 of
 the
 Institutional

Review
 Board
 at
 Boston
 University
 or
 the
 investigator
 in
 charge
 of
 the
 study.

 Their
 contact

information
 is
 on
 the
 copy
 of
 the
 consent
 form
 we
 mailed
 to
 you.

Do
 you
 wish
 to
 participate
 in
 the
 study?

YES
 .........................................................................
 1

NO
 .........................................................................
 2
 (GO
 TO
 THANK1)

S8.

You
 have
 the
 option
 of
 doing
 the
 survey
 now
 with
 me
 or
 I
 can
 schedule
 the
 interview
 for
 a

different
 time.

 You
 can
 also
 go
 on
 the
 Internet
 to
 complete
 the
 survey
 on
 your
 own.
 Which

would
 you
 prefer?

S9.

INTERNET
 ..............................................

  1
  (GO
 TO
 S9)

TELEPHONE
 NOW
 ..................................

  2
  (GO
 TO
 WEB
 SURVEY)

TELEPHONE
 LATER
 ................................

  2
  (GO
 TO
 APPT
 SCREEN;
 THEN
 THANK2)

We
 will
 send
 you
 an
 email
 with
 details
 and
 instructions
 for
 logging
 on
 to
 the
 web
 survey.
 May
 I

please
 have
 your
 email
 address?

[NOTE
 TO
 INTERVIEWER,
 RESPONDENT
 CAN
 NOT
 DO
 SURVEY
 ON
 INTERNET
 IF
 THEY
 DO
 NOT

HAVE
 AN
 EMAIL
 ADDRESS
 OR
 REFUSE
 TO
 PROVIDE
 AN
 EMAIL
 ADDRESS
 FOR
 US
 TO
 SEND
 THE

SURVEY
 LINK.]

4

Version
 6

6/26/14

THANK1.

THANK2.

THANK3.

E-­‐MAIL
 ADDRESS
 ____________________________

CONFIRM
 E-­‐MAIL
 ADDRESS
 ____________________

  (GO
 TO
 THANK3)

Thank
 you,
 but
 those
 are
 all
 the
 questions
 I
 have
 for
 you.
 Good-­‐bye.

Thank
 you
 for
 taking
 the
 time
 to
 answer
 these
 questions.
 We
 look
 forward
 to
 your

participation
 in
 our
 study.

Thank
 you
 for
 taking
 the
 time
 to
 answer
 these
 questions.
 You
 should
 receive
 an
 email

with
 a
 link
 for
 the
 web
 survey
 soon.
 We
 look
 forward
 to
 your
 participation
 in
 our
 study.

5

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 6

6/26/14