FDA RAPID – MESSAGE #2
Caregiver Factsheet
Recruiting Screener
Introduction
The U.S. Food and Drug Administration, or FDA, hired Westat to help them get opinions about health information. Research Now is helping Westat and FDA find people who may be interested in being interviewed about health information. To make sure you are a good fit for the interview, please take about 3 minutes to answer the questions below.
1. Do you currently help an ill, disabled, or elderly adult manage their medications, medical devices, medical appointments, or other medical needs?
Yes
No INELIGIBLE
2. Whose medical needs do you help manage? If you help more than one adult, select the person with the most medical needs.
Child 18 years or older
Spouse
Partner
Parent
Mother-in-law or father-in-law
Grandparent
Brother or sister
Friend
Other (please specify this person’s relationship to you)
3. What is this person’s main health problem or illness?
Chronic health condition like diabetes, or heart, kidney or lung disease
Cancer
Stroke
Memory problems, including Alzheimer’s or dementia
Congenital condition like cerebral palsy, autism, or Down’s syndrome
HIV/AIDS
Depression or other mental illness
Injury or short-term illness
Pain, mobility problems, or arthritis
Old age
Other (please specify the main health problem or illness)
Don’t know
4 How often do you help manage this person’s medical needs?
Just about every day
A few times a week
About once a week
About every other week
About once a month
Less than once a month INELIGIBLE
5 How long have you been helping manage this person’s medical needs?
Less than 6 months
6 months to less than 1 year
1 year to less than 3 years
3 years to less than 5 years
5 years or more
6. Do you live in the same home as this person?
Yes
No
7. Do you work outside of the home?
Yes
No
8. What is your gender?
Female
Male INELIGIBLE
9. What is your age?
Under 18 INELIGIBLE
18 to 34
35 to 49
50 to 64
65 or older
10. What is the highest grade or level of education you have completed?
Less than High School
High School Diploma or GED
Some College, including Associate’s Degree
Bachelor’s Degree (for example: BA, BS)
Graduate or Professional Degree INELIGIBLE
11. Are you of Hispanic, Latino, or Spanish origin?
YES
NO
12. What is your race? Please select one or more.
White
Black or African-American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander
Request for Contact Information
Thank you for answering the questions. Based on your answers, you may be chosen for an interview. If you are chosen for the interview and you finish it, you will get $35 E-Rewards Currency. At the start of the interview, the interviewer will ask if it’s okay to audio record it. This helps Westat to make sure they hear everything you say correctly. If you are chosen for an interview, you will get a package in the mail. Make sure to have the package with you during the interview. Is it okay with you for Research Now to share your contact information with Westat?
YES
NO INELIGIBLE
Thank and Terminate
We’re sorry, you are not a good fit for an interview at this time. Thank you for taking the time to answer the questions.
Contact Information
In the space below, please give us the best information to contact you by phone, email, and regular mail. Please know that Research Now and Westat will not share your information with anyone else.
Contact Information
Name ______________________________________________________________________
Address 1 ___________________________________________________________________
Address 2 ___________________________________________________________________
City, State, ZIP _______________________________________________________________
Phone Number _______________________________________________________________
Email Address________________________________________________________________
Available Times
Someone from Westat will call or email in the next 1-2 days to schedule an interview with you. Please mark the times you can be reached by phone in the next 1-2 days.
9 a.m. to Noon
Noon to 2 p.m.
2 p.m. to 5 p.m.
5 p.m. to 7 p.m.
7 p.m. to 9 p.m.
Technology Preferences
The Westat interviewer would like to be able to show you information on her computer screen during the interview. Westat will send directions for how to view the interviewer’s screen. Which app do you prefer for screen sharing?
Skype
Google Hangouts
Zoom
WebEx
I am not able to use any of these, please just call me
Closing
Thank you for your answers to these questions. If you are chosen for an interview, someone from Westat will contact you within the next 1-2 days.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Jocelyn Newsome |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |