Sample - Eligibility screener

Appendix B. Eligibility Screener SAMPLE

Form Approved

OMB No. 0923-0051

Exp. Date 02/28/2021

Appendix B Eligibility Screener Form

Date _____________ Start time _____________ End time ______________

Participant Name: ____________________________________________________

Eligibility Screener Form

INTERVIEWER INSTRUCTIONS: Indicate that the person is English speaking:

Yes Continue below

No If the person does not speak English, stop and seek an interpreter to complete this screener.

Hello, I’d like to find out if you are eligible to take part in the [health department] investigation of the recent [type of incident].

I would like to begin by showing you a map of the areas affected by the incident on [start date and time]. The affected areas are highlighted. From now on, I will refer to the [type of incident] on [start date and time] as “the incident.”

[SHOW MAP]

After reviewing a map of the exposed area(s), ask respondents the following question:

1. Were you in this area at any time between [start date and time] and [end date and time]?

Yes Say to the respondent: Now that we know you were in the area at that time, I’d like to be able to ask your consent to take part in our investigation. Go to consent form.

No Say to the respondent: Thank you for your time.

Do not ask any further questions. This person is not eligible for the survey.

Public reporting burden of this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS E-11 Atlanta, Georgia 30333; ATTN: PRA (0923-0051)