### EPA ICR No. **2487 .**  **01 ; OMB Control No. 2070** **- NEW** 

**ATTACHMENT C**  **Screening Questionnaire for General Adult Consumer Focus Group**



### OMB Control No. **2070 -** **NEW Approval expires**  **XX/XX/XX** The annual public burden for this collection of information is estimated at 0.17 hours per response for screened respondents , 2 hours for respondents that participate in the focus groups , 0.33 hours per response for pre - launch consumer online survey respondents, and 0.17 hours per response for post- launch online survey 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 Questio nnaire 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 Un ited 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 relatio ns 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? [GOOD MIX] 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 ... ? [RECRUIT 3 -4 MINORITIES] **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] [GOOD MIX] Male _____ Female _____ 1 0 . Have you ever attended a focus group discussion or individu al 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 ____

_A. How many of these groups have you attended? ______________________________ [MAX. 3 EVER] B. What was/were the topics discussed? ______________________________ [IF CHEMICAL SAFETY, TERMINATE] C. 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 . W e 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 hop e 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:

____________________