OMB No. 0930-0196
Expiration Date: 9/30/2019
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’d like to invite you to participate in an interesting research study on [DATE] AT [TIME]. There will be a 90-minute group discussion and participants will get a $50 gift card as a token of appreciation for their time.
Our client is developing some TV spots about recovery from mental and substance use disorders1, and would like your opinion about some ideas for these TV/radio spots (also called Public Service Announcements or PSAs for short). 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 11)
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”]
Are you available to participate in a 90-minute session during the week of: October 2017 at evening hours?
⃝ [Rockville, MD] Oct [TBA]. ⃝ [Chicago, IL] 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.
Do you or does anyone in your household work in advertising, marketing, the news media or political campaigns?
⃝ Yes [if Yes, terminate “Unfortunately, study specifications prohibit us from including anyone who either works in these fields or has someone in their household who works in these fields. Thank you for your interest.”
⃝ No [continue]
When was the last time you participated in a focus group, if ever?
⃝ Less than 1 year (If “less than 1 year,” terminate ““Unfortunately, study specifications prohibit us from including anyone who participated in a focus group less than 1 year ago. Thank you for your interest.”
⃝ One year or more [continue]
⃝ Never [continue]
How familiar would you say you are with substance use disorders? Would you say you are:
[Recruit 3 individuals who say that they are either “not familiar” OR “somewhat familiar” with mental and substance use disorders]
⃝ Not familiar
⃝ Somewhat familiar
⃝ Familiar
⃝ Very familiar
How familiar would you say you are with mental illness? Would you say you are
[Recruit 3 individuals who say that they are either “ not familiar” OR “somewhat familiar” with mental and substance use disorders]
⃝ Not familiar
⃝ Somewhat familiar
⃝ Familiar
⃝ Very familiar
Please let me know which one applies:
(Recruit 12 individuals for each location and a mix of at least two to three for each of the categories below)
I am a person in recovery [Recruit Go to Q 8]
I am a family member/caregiver, loved one/friend of someone in recovery or someone who has a mental or substance use disorder [Recruit Go to Q 8]
other, please explain
Are you in recovery from/is the person that you know recovering from/living with: [recruit a mix categories;]
⃝ Mental illness
⃝ Substance use disorder
⃝ Both
Age [recruit a mix – wait for response]
⃝ 18–28
⃝ 29–39
⃝ 40–50
⃝ 51–60
⃝ 61+
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
Educational level [recruit a mix – wait for response]
⃝ Elementary School
⃝ Middle School
⃝ High School
⃝ Some college
⃝ College and/or postgraduate degree
Gender [attempt to recruit an equal number of male and female]
⃝ Female
⃝ Male
Are you of Hispanic or Latino origins?
⃝ No, not of Hispanic or Latino origin
⃝ Yes, Mexican, Mexican Am., Chicano
⃝ Yes, Puerto Rican
⃝ Yes, Cuban
⃝ Yes, Salvadoran
⃝ Yes, another Hispanic or Latino origin – Print origin (e.g., Colombian, Nicaraguan) _________________________________________
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
Please select which option describes you best.]
⃝ I only speak Spanish. [Recruit for Spanish-speaking groups]
⃝ I am a Spanish-dominant speaker. [Recruit for Spanish-speaking groups]
⃝ I am bilingual in English and Spanish. [Recruit for English-speaking groups]
⃝ I am an English-dominant speaker. [Recruit for English-speaking groups]
⃝ I only speak English. [Recruit for English-speaking groups]
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 use disorder, mental illness and co-occurring disorders (both a mental and substance use disorder). (See Table below for desired participants’ distribution).
Recruit a mix of family members, loved one/friend of someone in recovery or with a current mental illness/substance use disorder. (See Table below for desired participants’ distribution).
Recruit individuals who are either “not familiar” or “somewhat familiar” with mental and substance use disorders. (See Table below for desired participants’ distribution).
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 for the Spanish Focus Groups)
PARTICIPANTS’ DESIRED DISTRIBUTION
|
FG 1/ MD ENGLISH |
FG 2/MD SPANISH |
FG 3/FL ENGLISH |
FG 4/FL SPANISH |
TOTAL |
Desired # of screened participants |
12 |
12 |
12 |
12 |
48 |
Desired number of selected participants |
11 |
11 |
11 |
11 |
44 |
Gender |
|
|
|
|
|
Female |
5 |
6 |
5 |
6 |
22 |
Male |
6 |
5 |
6 |
5 |
22 |
Ages |
|
|
|
|
|
18–28 |
3 |
2 |
2 |
2 |
9 |
29–39 |
2 |
3 |
2 |
2 |
9 |
40–50 |
2 |
2 |
3 |
2 |
9 |
51–60 |
2 |
2 |
2 |
3 |
9 |
61 + |
2 |
2 |
2 |
2 |
8 |
Categories |
|
|
|
|
|
Individuals in recovery |
2 |
2 |
2 |
2 |
8 |
Family members, loved ones friends of someone in recovery or who are in need or treatment/recovery services |
3 |
3 |
3 |
3 |
12 |
Individuals who are “not familiar” or “somewhat familiar” with mental or substance use disorders |
6 |
6 |
6 |
6 |
24 |
Ethnicity/Race |
Attempt a mix of ethnic/racial groups. For Hispanic/Latinos attempt a mix of countries of Origin |
44 |
|||
Education/income |
Attempt a mix of educational and income levels |
44 |
|||
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.
ATTACHMENT A – Screening and Recruiting Questionnaire
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Luz Amparo Pinzon |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |