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        Screening Questionnaire for General Adult Consumer Focus Group
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                           OMB Control No. 2070-0189
                           Approval expires 02/28/17
                                       
 The annual public burden for this collection of information is estimated at 0.17 hours per response for screened respondents. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed application to this address.
                                       
         Screening Questionnaire for General Adult Consumer Focus Group

Interviewer:               _______________

Date:                          _______________

Letter sent:                 _______________

Reconfirmation Call:  _______________




                        CALL FROM DATABASE OR AT RANDOM
                      RECRUIT 9 PER GROUP FOR 8-9 TO SHOW

Hello, I'm __________ with __________________, an independent consumer research firm. We are not selling or promoting any product or service. We are conducting a research study on behalf of the United States Environmental Protection Agency about providing information to help consumers select products that are safer for people, families, and pets and can help protect the environment, and would like to include your views. My questions will only take a couple of minutes. 

1.	First, do you, or does any member of your household or immediate family, work for or is retired from:
                                                A market research company _____
                        A direct mail company or direct marketing company _____
                           An advertising agency or public relations firm _____
                                                                   The media (TV/radio/newspapers/magazines) _____
                                                                               
                      [IF YES TO ANY >> TERMINATE]
                                       
2.	Are you a chemist, chemical engineer, or organic farmer  -  or do you work for EPA, an environmental agency or environmental non-profit, or the organic food industry?  	

                      [IF YES TO ANY >> TERMINATE]

3.	In a typical month, how frequently do you shop at a grocery store, supermarket, hardware store, home improvement store (such as Home Depot or Lowe's) or general retail store (such as WalMart, Target, Costco, or Sam's Club) for your household?   
                                                          4 or more times _____
                                                             2 or 3 times _____
                                    TERMINATE >> Fewer than 2 times _____

4.  	Which of the following categories best describes your total annual household income?  
                                         TERMINATE >> Under $15,000 _____
                                                        $15,000 - $34,999 _____
                                                        $35,000 - $54,999 _____
                                                        $55,000 - $74,999 _____
                                                       $75,000 - $100,000 _____
                                         TERMINATE >> Over $100,000 _____

5. 	Please tell me your age. 
                                                                               
                              [Record age; GOOD MIX OF AGES 21+]

                                                                               
6.	What is your current marital status?  Are you ..... ?	
                                          Married or living with a partner_____
                                                                   Single _____
                                                                 Divorced _____
                                                                  Widowed _____
                                                                               
7.	What is the highest level of education you have completed?	 
                                           Less than high school graduate _____
                                                     High school graduate _____
                                                             Some college _____
                                						                College graduate _____   
                                          Post graduate studies or degree _____

8.	So that we can be sure that all backgrounds are represented in our study, please tell me your ethnic or race background. Are you ... ? 
                                                Ethnicity
                                       
                                                        Hispanic or Latino_____
                                                   Not Hispanic or Latino_____ 
                                                
                                                Race
                                                
                                         American-Indian or Alaska Native _____
                                                                    Asian _____
                                                Black or African American _____
                         Native Hawaiian-Indian or Other Pacific Islander _____
                                                                    White _____
                                                                    Other _____
                                                                               

9.	[Record gender] 
                                                                     Male _____
                                                                   Female _____
                                                                               
10.	Have you ever attended a focus group discussion or individual interview?  By that we mean an informal, round-table discussion, conducted by a professional moderator in which you were asked your opinions regarding a product, a service, or advertising?
                             MAX. (1/2) GROUP  >> ASK A-C >> Yes _____
                                              INVITE TO GROUP >> No _____
 How many of these groups have you attended?
            ______________________________  [MAX. 3 EVER]
 What was/were the topics discussed?
            ______________________________  [IF CHEMICAL SAFETY, TERMINATE]
 How long ago was the last one of these groups you attended?
            ______________________________  [MUST BE AT LEAST 6 MONTHS AGO]
                               [INVITE TO GROUP]

Thank you for answering all of my questions. As I mentioned earlier, we are conducting a research study regarding information to help consumers select products that are safer for families and can help protect the environment. We are conducting an informal, round-table discussion to be held on _______ at _______. The discussion will last about two hours and will be both fun and informative. No one will attempt to sell you anything and no one will call on you as a result of your participation. As a token of our appreciation for your help in our research effort, you will receive a $100 cash honorarium at the time of the session. This is an important research effort and we hope that you will be part of it. We can only invite about a dozen people to take part. Can we schedule your attendance?
[If yes, read ... ]
If you need glasses for reading or for watching TV, please be sure to bring them with you to the group.

ID Number	_________________________________________________

NAME:	_________________________________________________
ADDRESS:	_________________________________________________
CITY:		_________________________________________________
ZIP CODE:	_________________________________________________
PHONE:	(DAY)		_____________________________________
		(EVE)		_____________________________________
		(CELL)		_____________________________________
		(EMAIL)	_____________________________________

Interviewer:		____________________
Supervisor Confirm:	____________________

