Rapid Message Testing with Consumer Panel - Vaccines and Seniors Brochure

FDA RAPID – MESSAGE #7

Vaccines for Seniors Trifold

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. What is your gender?

1. Female

2. Male

2. What is your age?

1. Under 18  INELIGIBLE

2. 18 to 30  INELIGIBLE

3. 31 to 44  INELIGIBLE

4. 45 to 64  INELIGIBLE

5. 65 or older

3. 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)  INELIGIBLE

5. Graduate or Professional Degree  INELIGIBLE

4. Do you currently work for pay?

YES

NO  GO TO Q6

5. What kind of work do you do?

OPEN-ENDED TEXT BOX

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

YES

NO

7. 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

IF Q6=No AND Q7=White, INELIGIBLE.

8. Is English your first language?

Yes

No

9. How well do you speak English?

Very well

Well

Not well

Not at all

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

10. What is your yearly household income?

$24,999 or less

$25,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000 to $149,999

$150,000 to $199,999

$200,000 or more

Request for Contact Information

C1. 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

Thank you for taking our survey.

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 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

C3. 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

C4. 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? [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.