1B Attachment 1-B. Study 1 Recruitment screener

Form Approved
OMB No. 0935.0124
Exp. Date 1/31/2024

Recruitment Screner – Study 1

INTRODUCTION SCREEN. Thank you for your interest in an upcoming study that Westat is conducting.

Westat is working on this project for the Agency for Healthcare Quality and Research, AHRQ, which is part of the U.S. Department of Health and Human Services. We are testing ways to improve data quality for the Medical Expenditure Panel Survey, or MEPS.

In this study, we will be asking you to participate in three Zoom interviews, roughly every three weeks. If you are interested and eligible, the first two interviews will take approximately 30 minutes each. In each of these interviews, the interviewer will ask you to respond to a web survey over Zoom while they observe you. The third interview will last 90 minutes and the interviewer will ask you detailed questions about you and your household’s recent health care events. As a token of appreciation for your time, you will receive a $25 electronic gift card for each of the 30-minute interviews and a $75 electronic gift card for the 90-minute interview. So if you participate in all three parts of the study, you will receive a total of $125.

Everything that you say will be confidential – that is, no one outside the research team will know what you told us.

To see if you are eligible for the study, please answer the following questions. If you prefer not to answer a question or don’t know the answer, click the “next” button to continue.

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Your participation is voluntary and all of your answers will be kept confidential to the extent permitted by law. Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0124) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

DEMOGRAPHIC INFORMATION

1. What is your age?

[ENTRY FIELD FOR NUMBERS]

[IF REFUSING OR SKIPPING, GO TO SOFT PROMPT 1]

SOFT PROMT 1

In order to be eligible, you need to answer all questions [IF STILL REFUSING OR SKIPPING, GO TO INELIGIBLE STATEMENT]

[IF PARTICIPANT IS UNDER 18 THEN GO TO INELIGIBLE STATEMENT]

INELIGIBLE STATEMENT.

Thank you very much for your interest and your time, but you are not eligible for this study.

2. What is your gender?

• Female

• Male

• Other – Specify [TEXT BOX]

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

• Yes

• No

4. What is your race? [MARK ALL THAT APPLY]

• White

• Black or African American

• Asian

• Native Hawaiian or other Pacific Islander

• Other – Specify [TEXT BOX]

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

• Less than High School

• High School Diploma/GED

• Some college (Includes Associate’s)

• College graduate (BA, BS)

• Graduate/Professional degree (MA, MS, MD, JD, PhD, etc.)

6. What state do you live in?

[DROPDOWN BOX WITH STATE NAMES]

7. What is your current zip code?

[ENTRY FIELD FOR NUMBERS]

HOUSEHOLD ROSTER

8. Including yourself, how many people living in your household are in each of the following age groups? (Please enter a number from 0 to 6 in each row. If there are more than 6 people in a category, enter 6.)

1. Ages 18 to 64 [ENTRY FIELD FOR NUMBERS]

2. Ages 65 or above [ENTRY FIELD FOR NUMBERS]

3. Ages 17 or younger [ENTRY FIELD FOR NUMBERS]

[SUM RESPONSES FROM Q8A, Q8B, Q8C TO OBTAIN Q8]

9. {IF Q8 > 1 THEN DISPLAY: Please list the names (or initials or nicknames) of each person living here. This information will be used during the interviews to ask you questions about each person and will not be used for any other purpose.

Enter your name in the first row:

ELSE IF Q1=1 DISPLAY: Please provide your first and last name (or initials or nickname) in the boxes below: }

	First name (or initials or nickname)	Last name
1

IF Q8 > 1 THEN DISPLAY: Please list the first and last names (or initials or nicknames) of the other persons living here:

[PROGRAMMING NOTE: PRESENT AS MANY ROWS AS NEEDED TO MATCH THE COUNT IN Q8]

	First name (or initials or nickname)	Last name
2
3
4
N

HEALTH CARE VISITS – PAST 3 MONTHS

10. In the last 3 months (between [DATE 3 MONTHS AGO] and today), have you {IF Q8 > 1 THEN DISPLAY: or any people in your household} had any doctor’s visits or received any health care services? Think about services like:

• Hospital or emergency room visits, doctor’s office visits, or visits to a health clinic or urgent care center

• Dental or vision care, or lab tests

• Mental health care, physical or occupational therapy

• Alternative care like acupuncture, home-based health care, or care in a rehabilitation or treatment facility

• Yes

• No [GO TO Q12]

11. Including yourself, approximately how many health care visits did all people in your household have in the past 3 months?

• 1 visit

• 2 to 5 visits

• 6 to 10 visits

• More than 10 visits

HEALTH CARE VISITS – UPCOMING 3 MONTHS

12. In the next 3 months (between now and [DATE 3 MONTHS FROM NOW], do you expect that you {IF Q8 > 1 THEN DISPLAY: or any people in your household} will have any doctor’s visits or receive any health care services? Think about services like:

• Hospital, doctor’s office visits, or visits to a health clinic or urgent care center

• Dental or vision care, or lab tests

• Mental health care, physical or occupational therapy

• Alternative care like acupuncture, home-based health care, or care in a rehabilitation or treatment facility

• Yes

• No [GO TO Q14]

• Don’t know [GO TO Q14]

13. Including yourself, approximately how many health care visits are expected for the next 3 months across all of the people in your household?

• 1 visit

• 2 to 5 visits

• 6 to 10 visits

• More than 10 visits

• Don’t know

ZOOM CAPACITY

Thank you for your answers so far.

14. Have you ever used Zoom before?

• Yes [GO TO #16]

• No

15. Are you willing to use Zoom for the study?

• Yes

• No [GO TO INELIGIBLE STATEMENT]

16. This study will be conducted over the next 3 months and will require your participation in 3 different interviews, roughly every 3 weeks. The first 2 interviews will last approximately 30 minutes. The last interview will last approximately 90 minutes. Are you interested in participating in this study if we determine that you are eligible? (Please note we may not be able to include everyone who is interested in participating.)

• Yes [GO TO NEXT SECTION]

• No [GO TO INELIGIBLE STATEMENT]

CONTACT INFORMATION

If you are eligible to participate, we will contact you to schedule your first Zoom interview. Please provide your contact information.

17. What is your name? [TEXT BOX]

18. What is your phone number? [TEXT BOX]

19. What is your email address? [TEXT BOX]

[IF SKIPPED OR MISSING INFORMATION IN Q24, Q25 OR Q26, SHOW SOFT PROMPT 2]

SOFT PROMPT 2

We will not be able to contact you if you do not provide us the requested information.

[IF SKIPPED OR MISSING INFORMATION AGAIN IN Q25 OR Q26, SHOW INELIGIBLE STATEMENT]

Thank you. If you are selected to participate, we will contact you soon in order to schedule your first Zoom interview and to answer any questions you may have about the study.

Attachment 1B: Study 1 Recruitment Screener 1B-9