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OMB #: 0970-0355 Expiration Date:
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Screener for ASR Feasibility Study
Hello, my name is [NAME] from Research Support Services. I am calling you about a study we are doing with the Urban Institute on behalf of the U.S. Office of Refugee Resettlement about how refugees adapt to life in the U.S. Research Support Services and the Urban Institute are both independent research organizations. Hopefully, you received a letter in the mail about it in the last week or two. We would like to invite you to participate.
The study interview takes 75 minutes and participants receive a $40 token of appreciation to thank them for participating. The interview is done online on Zoom, and we can help you connect to Zoom if you are not sure how to do it. To participate, we will need to audio- and video-record the Zoom session; the recording will only be seen by the research team and it will be destroyed after the research is completed.
To make sure you are eligible for the study, I would like to ask you a few questions. This will only take a couple of minutes. Would that be okay?
1. What is your age?
|___|___|
2. In what country were you born? ________________________
3. In what year did you move to the United States? ______________________
4. What is your gender?
1. __ MALE
2. __ FEMALE
3. __ SOME OTHER RESPONSE
6. How many adults and children in total live with you?
|___|___| total number in household
7. The interview will be completely in (Language) and it is not necessary to speak English. But I need to ask you how well you speak English so that we can describe the study participants in our report. Would you say you speak English very well, well, not well, or not at all?
1. __Very well
2. __Well
3. __Not well
4. __Not at all
8. How well do you read (LANGUAGE)? Would you say you read (LANGUAGE) very well, well, not well, or you don’t read (LANGUAGE) at all?
1. __Very well
2. __Well
3. __Not well
4. __Not at all
9. If you are eligible to participate, do you have access to a computer, tablet or smartphone with an Internet connection, for the online video interview?
1. __ Computer or tablet
2. __ Smartphone
0. __ None
10. We need to video record the interview so that we can carefully review the discussion and draw the proper conclusions. Will that be alright with you?
1. __ YES
0. __ NO
11. Can I have your name and the best phone number to reach you to set up an interview if you qualify?
Name_________________________________________________________________________
Phone Number______________________________________________________________
COLLECT EMAIL ADDRESS AND TIME OF THE CALL
Email address______________________________________________________________
Time ____________________________________________________________________
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to conduct a feasibility test for implementing an online version of the Annual Survey of Refugees (ASR). Public reporting burden for this collection of information is estimated to average 1.5 hours per grantee, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0355 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact asr@acf.hhs.gov.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Wantz, Joseph (ACF) (CTR) |
File Modified | 0000-00-00 |
File Created | 2024-07-23 |