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 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? [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 _____

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 _____
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. 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: ____________________