Rapid Message Testing with Consumer Panel - Storyboards About Safe Disposal of Opioids and Other Medicines

OMB Control No. 0910-0695

Expiration date: 2/28/2021

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 0910-0695 and the expiration date is 2/28/2021. The time required to complete this information collection is estimated to average 3 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information.

FDA RAPID – MESSAGE #20

“What it Spells”

Recruiting Screener

Introduction

The U.S. Food and Drug Administration, or FDA, hired Westat to help them get opinions about health information. Area Wide 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. What is your age?

1. Under 18  INELIGIBLE

2. 19 to 29

3. 30 to 39

4. 40 to 49

5. 50 to 59

6. 60 to 69

7. 70 or older

2. Do you, or does any member of your household or immediate family work…?

1. For a market research company  INELIGIBLE

2. For an advertising agency or public relations firm  INELIGIBLE

3. In the media (TV, radio, newspapers, magazines)  INELIGIBLE

4. As a healthcare professional (doctor, nurse, pharmacist, medical assistant, dietician, etc.)  INELIGIBLE

5. In the pharmaceutical industry  INELIGIBLE

6. None of the above  GO TO Q3

3. Have you been prescribed any of the following pain relievers in the last 3 years? Select all that apply.¹

1. Hydrocodone acetaminophen, Vicodin, Lortab, Lorcet, Norco, or Zydone

2. Hydrocodone extended-release, Zohydro, or Hysingla

3. Hydromorphone extended-release, Exalgo or Dilaudid

4. Oxycodone acetaminophen, Percocet, Endocet, or Primlev

5. Oxycodone, Oxycontin, Oxy IR, Oxyfast, Percodan, Roxicet, Roxicodone,
   Roxybond, Targiniq ER, Xartemis XR, or Xtampza ER

6. Tramadol or Ultram

7. Codeine acetaminophen, Tylenol #3, Tylenol #4, or Vopac

8. Morphine, MS Contin, Morphine Sulfate ER, Morphine Sulfate IR, or Kadian

9. Methadone or Dolophine

10. Oxymorphone or Opana

11. Buprenorphine skin patch or film, Butrans, or Belbuca

12. Tapentadol, Nucynta, or Nucynta ER

13. Fentanyl skin patch or Duragesic

14. Immediate Release Fentanyl tablets, lozenges, films or sprays, Abstral, Actiq, Fentora, Lazanda, Onsolis, or Subsys

15. Another opioid medicine

16. None of the above

17. Don’t know

4. Have you been prescribed any medicines that are not pain relievers in the last year?

1. Yes

2. No

5. Which of the following describe your role? Select all that apply.

1. A parent or step-parent of a child or children living in your household

2. A grandparent who lives with or watches a grandchild or grandchildren regularly in your own home

3. A person who provides ongoing, unpaid care for the medical needs of an adult family member

4. A person who provides ongoing, unpaid care for the medical needs of an adult friend

5. None of the above  INELIGIBLE if Q3=P or Q OR Q4=No

6. [Ask if Q5=A, B, C, or D] Has a child or adult for whom you provide unpaid care been prescribed any of the following pain relievers in the last 3 years? Select all that apply.²

1. Hydrocodone acetaminophen, Vicodin, Lortab, Lorcet, Norco, or Zydone

2. Hydrocodone extended-release, Zohydro, or Hysingla

3. Hydromorphone extended-release, Exalgo or Dilaudid

4. Oxycodone acetaminophen, Percocet, Endocet, or Primlev

5. Oxycodone, Oxycontin, Oxy IR, Oxyfast, Percodan, Roxicet, Roxicodone,
   Roxybond, Targiniq ER, Xartemis XR, or Xtampza ER

6. Tramadol or Ultram

7. Codeine acetaminophen, Tylenol #3, Tylenol #4, or Vopac

8. Morphine, MS Contin, Morphine Sulfate ER, Morphine Sulfate IR, or Kadian

9. Methadone or Dolophine

10. Oxymorphone or Opana

11. Buprenorphine skin patch or film, Butrans, or Belbuca

12. Tapentadol, Nucynta, or Nucynta ER

13. Fentanyl skin patch or Duragesic

14. Immediate Release Fentanyl tablets, lozenges, films or sprays, Abstral, Actiq, Fentora, Lazanda, Onsolis, or Subsys

15. Another opioid medicine

16. None of the above  INELIGIBLE if Q3=P or Q

17. Don’t know  INELIGIBLE if Q3=P or Q

7. [Ask if Q5=A, B, C, or D] Has a child or adult for whom you provide unpaid care been prescribed any medicines that are not pain relievers in the last year?

1. Yes

2. No INELIGIBLE if Q3 and Q6 = P or Q OR Q4=No

8. What is your sex?

1. Female

2. Male

9. What is the highest grade or level of education you have completed?

1. Less than High School

2. High School Diploma or GED

3. Some College, including Associate’s Degree

4. Bachelor’s Degree (for example: BA, BS)

5. Graduate or Professional Degree  INELIGIBLE

10. Are you of Hispanic, Latino, or Spanish origin?

YES

NO

11. 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

12. What language do you speak most often at home?

English GO TO Q14

Spanish GO TO Q13

Other  INELIGIBLE

13. [Ask if Q12=Spanish] How well do you speak Spanish?

Very well

Well  INELIGIBLE

Not well  INELIGIBLE

Not at all  INELIGIBLE

14. What state do you live in? [DROP DOWN LIST OF US STATES, INCLUDING “OUTSIDE OF THE US”] [“OUTSIDE OF THE US”  INELIGIBLE]

Request for Contact Information

C1. Thank you for answering these questions. Based on your answers, you may be selected for an interview. If selected and you finish it, you will get $50. 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 packet in the mail/an email] for this study. Make sure to have [the packet with you/access to your email] during the interview. Is it okay with you for Area Wide to share your contact information with Westat?

YES

NO  INELIGIBLE

Thank and Terminate

Thank you for taking our survey. Unfortunately, based on your responses, you are not eligible for this study. However, we appreciate you taking the time to answer our questions today.

Contact Information

C2. In the space below, please give us the best information to contact you by phone, email, and regular mail. Please know that Westat will not share your information with anyone else. Your personal information will be deleted upon completion of the research project.

Contact Information

Name ______________________________________________________________________

Address 1 ___________________________________________________________________

Address 2 ___________________________________________________________________

City, State, ZIP _______________________________________________________________

Phone Number _______________________________________________________________

Email Address________________________________________________________________

Technology Preferences

C3. 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 do this. Which app do you prefer for screen sharing? [SINGLE SELECT]

1. Skype

2. Google Hangouts

3. WebEx

4. 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 with the next 1-2 days.

1 Loosely based on 2016 NSDUH. See pages 201 and 224. https://www.samhsa.gov/data/sites/default/files/NSDUHmrbCAIquex2016v2.pdf

2 Loosely based on 2016 NSDUH. See pages 201 and 224. https://www.samhsa.gov/data/sites/default/files/NSDUHmrbCAIquex2016v2.pdf