Form Approved
   OMB No. 0990-0281
   Exp. Date XX/XX/XX12

Focus Group and Interview Recruitment Screener

Interviewer:    _________________________________

Date:               _________________________________

Letter sent:     _________________________________

Reconfirmation Call:  ___________________________
	
HP Web Site Focus Groups
Segmentation Groups

Group 1   _____  [State Level] 
Group 2   _____  [State Level]
Group 3   _____  [Local Level]
Group 4   _____  [Local Level] 
Group 5   _____  [Community Based]
Group 6   _____  [Community Based]
	HP Web Site Interviews
Segmentation Groups

Group 1   _____  [State Level] 
Group 2   _____  [Local Level]
Group 3   _____  [Community Based]	

OMB BURDEN STATEMENT:   According to the Paperwork Reduction Act of 1995, no persons are 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 0990-0281. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:  U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington D.C. 20201,  Attention: PRA Reports Clearance Officer 

IQ Solutions Inc.
ODPHP Healthy People Web Site 
Focus Group and Interview Recruitment Screener

CALL FROM LIST OF HEALTH PROFESSIONALS SEGMENTED BY LEVEL OF ORGANIZATION, STATE, CITY, URBANICITY AND TYPE OF ORGANIZATION.

Hello, I’m __________ with __________________, an independent research firm.  We are conducting a project to better understand how health professionals use web based health resources and their interest in a web based community health planning tool.  Would you be interested in potentially participating in a telephone discussion on this topic?

___	Yes.  (Continue)
___	No. (Thank and terminate call)

I received your name from a federal agency that works with health professionals.  I would like to ask you a few questions and review some information that I already have collected on your organization.

1.	I have noted that you work for (name of organization) ___________________________.  Is this true?	
		_____  Yes. (continue to Q2)
		_____   No.  (Thank and terminate call)

2.	I have noted that this organization is a:
		_____	State Level organization (responsible for statewide activities/planning)
		_____  Local level organization (funded by State, working at local level)
_____ 	Community based organization (works at community level, not affiliated with State Health Department). 

Is this true?
		_____  Yes. (continue to Q3)
		_____   No.  (How would you categorize your organization? __________________)
(Recategorize according to respondent and determine need for that segmentation group).

3.	How would you categorize the geographic area in which your primary target audience resides:
		____	City
		____	Suburban
		____	Rural	
		____	Mix	

4.	What region of the country do you work in:
		____	East Coast
		____	Midwest
		____	South
		____	West Coast

5.	What type of work do you do:
		____	Program Planning
		____	Direct Services 
		____	Health Education
		____	School Based
		____	Special Population Based
		____	Other, (Please specify ________________________________)

6.	Do you have access to the Internet at your place of employment?
		____	Yes
		____	No (Thank and terminate call.)

On selection sheet, note availability of appropriate slot for each screening respondent.  If availability exists, proceed to invite respondent to participate in either a focus group or an interview:

[INVITE TO FOCUS GROUP]

Thank you for answering all of my questions. As I said earlier, we are talking to health professionals about their use of Web based health information for program planning and to get their reaction to a new Healthy People 2020 web site. We would like to hear your views. In order to hear them first-hand, we are holding a telephone/online focus group on [DATE] at [TIME]. The focus group will last about 2 hours and will be both fun and informative. You will receive a payment of $75.00 for your participation. This is an important project, and we hope that you will be part of it. May we schedule you for a focus group?

[INVITE TO INTERVIEW] 

Thank you for answering all of my questions. As I said earlier, we are talking to health professionals about their use of Web based health information for program planning and to get their reaction to a new Healthy People 2020 web site. We would like to hear your views. In order to hear them first-hand, we are holding a telephone/online interview on [DATE] at [TIME]. The interview will last about 1 hour and will be both fun and informative. You will receive a payment of $50.00 for your participation. This is an important project, and we hope that you will be part of it. May we schedule you for an interview?

	Invited for Focus Group				Invited for Interview

NAME:	_________________________________________________
ORGANIZATION:  ____________________________________________
ADDRESS:	_________________________________________________
CITY:		_________________________________________________
ZIP CODE:	_________________________________________________
PHONE:	(DAY)		_____________________________________
		(FAX)		_____________________________________
		(EMAIL)	_____________________________________
Interviewer:		____________________
Supervisor Confirm:	____________________