Rapid Message Testing with Consumer Panel - Testosterone Medication Guide

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 #11

Testosterone Medication Guide

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  INELIGIBLE

2. Male

2. What is your age?

1. Under 40  INELIGIBLE

2. 40 to 49

3. 50 to 59

4. 60 or older  INELIGIBLE

3. Do any children 17 years old or younger live in your household?

YES

NO  GO TO Q5

Don’t Know  INELIGIBLE

4. What age are the children living in your household? Mark all that apply.

1. 4 years old or younger

2. 5 to 7 years old

3. 8 to 12 years old

4. 13 to 17 years old

5. 18 years old or older  INELIGIBLE if not Yes to Q4a-d

5. 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 Cllege, including Associate’s Degree

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

5. Graduate or Professional Degree  INELIGIBLE

6. Do you currently work for pay?

YES

NO  GO TO Q8

7. What kind of work do you do?

OPEN-ENDED TEXT BOX

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

YES

NO

9. 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

10. 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 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 $50 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. 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 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 within the next 1-2 days.