Rapid Message Testing with Consumer Panel - Safe Drug Disposal Notecard

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 #15

Safe Drug Disposal

Introduction

The U.S. Food and Drug Administration, or FDA, hired Westat to help them get opinions about health information. EurekaFacts 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. In the past 12 months, have you used or taken medication for which a prescription is needed? Do not include prescription vitamins or minerals.¹

YES

NO

Don’t Know  INELIGIBLE

2. Do you currently help manage medications for an ill, disabled, or elderly adult? Managing medications includes talking with this person’s healthcare provider about medications, picking up prescriptions from the pharmacy, or giving medications to the person.

1. Yes  GO TO Q3

2. No  GO TO Q4, OR INELIGIBLE IF Q1 ALSO NO

3. Whose medications do you help manage? If you help more than one adult, select the person with the most medications.

1. Child 18 years or older

2. Spouse

3. Partner

4. Parent

5. Mother-in-law or father-in-law

6. Grandparent

7. Brother or sister

8. Friend

9. Other (please specify this person’s relationship to you)  INELIGIBLE IF PROFESSIONAL CAREGIVER

4. What is your gender?

1. Female

2. Male

5. What is your age?

1. Under 18  INELIGIBLE

2. 18 to 29

3. 30 to 49

4. 50 to 65

5. 66 or older  INELIGIBLE

6. 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

7. Do you currently work for pay?

YES

NO  GO TO Q9

8. What kind of work do you do?

OPEN-ENDED TEXT BOX  INELIGIBLE IF HEALTHCARE PROFESSIONAL

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

YES

NO

10. 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

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

English  ELIGIBLE for English interview  GO TO Q16

Spanish

Other  INELIGIBLE

12. How well do you speak Spanish?

Very well

Well

Not well  INELIGIBLE

Not at all  INELIGIBLE

13. How well do you read Spanish?

Very well ELIGIBLE for Spanish interview if Q12 is Very well or Well

Well ELIGIBLE for Spanish interview if Q12 is Very Well or Well

Not well  INELIGIBLE

Not at all  INELIGIBLE

14. How well do you speak English?

Very well

Well

Not well

Not at well

15. How well do you read English?

Very well  ELIGIBLE for bilingual English interview if Q11=Spanish and Q14 is Very Well or Well

Well  ELIGIBLE for bilingual English interview if Q11=Spanish and Q14 is Very Well or Well

Not well

Not at well

16. 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 the interview. If you are chosen for the interview and you finish it, you will get $35. 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 EurekaFacts 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 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 will contact you within the next 1-2 days.

1 Based on 2013-2014 National Health and Nutrition Examination Survey (NHANES)