An Investigation of Allergy to Cosmetics in the United States

Appendix A

OMB Control No. 0910-0497 Expiration Date: 10/31/2020

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0910-0497 and the expiration date is 10/31/2020. The time required to complete this information collection is estimated to average 8 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information.

Cosmetics & Allergens
Final Screening Questionnaire
[Date, Time]

Name:
Address:
City:			State:			Zip:
Home Phone:				Work Phone:

Hello, this is _____________ from [facility], a local market research firm. May I please speak to_____________?

(Hello, this is _____________ from [facility], a local market research firm.) We are working with RTI, a nonprofit research organization, on a research study sponsored by a federal government agency. We would like to hear how you use certain beauty, personal hygiene, or makeup products. We are holding a discussion on [date] with a small group of people like yourself. The discussion group starts at [time]. It will last no longer than 1.75 hours and will be audio- and video-recorded for study purposes. The discussion group is for research purposes only and is in no way sales related.

If you are selected and choose to participate in this discussion group, you will receive $75 as a token of our appreciation. First, however, I need to ask you a few questions to see if you qualify for the study. Is that ok with you?

Yes

No Thank & terminate.

Record Gender (Do not ask.)

Male

Female

1. I’m going to read a list of products. Please tell me which products you have bought in the past month? (Read list.)

Face cleanser

Shower gel

Vitamins

Bandages

Facial tissue

Hairspray

Toothpaste

2. Do you have any children ages 5 years old or younger living in your household?

Yes

No Go to Question 5.

3. Do any of your children who are 5 years old or younger have any allergies that affect how you purchase certain hair, body, or face products for them to use?

Yes

No Go to Question 5.

4. Has your child’s allergy been confirmed by a patch test performed by a healthcare professional?

Yes Recruit for Parents Group but Go to Question 6.

No

5. Do you have any allergies that affect how you purchase or use certain hair, body, or face products?

Yes Recruit for Allergy Groups

No Recruit for Non-Allergy Groups

6. In the past 5 years, have you or any member of your household worked for a market research, advertising, or public relations firm?

Yes Thank & terminate.

No

7. In the past 5 years, have you or any member of your household worked for a company that makes skin or hair products?

Yes Thank & terminate.

No

8. In the past 5 years, have you or any member of your household worked as a doctor, nurse, or other healthcare professional? [IF NECESSARY, READ: A health care professional includes physician’s assistant, nurse practitioner, medical assistant, pharmacist, or other individual who provides health care.]

Yes Thank & terminate.

No

9. In the past 5 years, have you or any member of your household worked for the federal government?

Yes Thank & terminate.

No

10. Have you participated in a focus group or paid research discussion group in the past 6 months?

Yes Thank & terminate.

No

11. For study purposes, the discussion group will be audio- and video-recorded. During the focus group, no sensitive questions will be asked. Are you okay with us recording your participation in the discussion?

Yes Continue.

No Thank the respondent and terminate.

12. During the discussion, you will be asked to review written materials and offer your opinions; therefore, I need to ask whether you have a medical or non-medical condition that hinders your ability to read and/or understand written materials.

Yes Thank the respondent and terminate.

No

Thank you. You qualify for the study, but I would like to ask you four more questions about yourself. Your answers to these questions will help us ensure we have a group that reflects the people living in our city.

13. Which of the following categories best describes your age? (Read list. Recruit a mix to show per group.)

Under 18 Thank & terminate.

18 to 24

25 to 34

35 to 44

45 to 59

60+

14. Are you Hispanic or Latino?

Yes

No

15. What is your race? Please select one or more. (Read list. Recruit a mix to show per group that reflects local population)

White

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native

16. What is the last grade of school you completed? (Read list. Recruit a mix to show per group.)

High school graduate or less, including GED

Some college or 2-year degree

4-year college degree

Postgraduate degree

IF RESPONDENT IS NOT NEEDED BASED ON DEMOGRAPHIC CHARACTERISTIC, READ:

Based on your responses, we have filled up all our available slots for your general profile.  If we have anyone drop out who is similar to you, we will call you back to see if you are available. Thanks for taking time to answer our questions.

OTHERWISE, READ:

That is all the questions I have. We would like to invite you to participate in the discussion group, which is on [date] at [time] and will last no longer than 1.5 hours. For your time and opinions, you will receive a $75 cash honorarium.

17. Would you like to participate in the group discussion at [time] on [date]?

Yes

No Thank & terminate.

Great! May I please have your email address to send you a confirmation letter with directions before the group discussion? [If no email,] may I please have your mailing address? [Verify address and phone number.]

Thank you. That’s all the questions I have today. Please arrive at least 15 minutes before the start of the group to ensure you have time to sign in and to get a meal/snack.

Read if necessary:
If you have any questions about the study, you may contact Katherine Kosa of RTI at 1‑800‑334‑8571, extension 23901.