#75207068 ID# 

CHOLESTEROL STUDY (0 1-05) 

SCWENING QUESTIONNATW 

Quota Groups 

8 Poughkeepsie 

9 Schenectady 3 45-59 

10 Seminole 4 60 and over 

5 Colorado Springs 11 Toledo START: 

12 Wichita STOP: 

Hello, I'm from U.S.Research, a nationwide market research company. I assure you 

that we are not selling anything ... all we want are your honest opinions. Could you spare us a few 

minutes to answer some brief questions? 

A, Wow concerned are you about your cholesterol level? Are you (EAD LIST. CRCLE 

ONE ANSWER) 

1 very concerned, (CONTINUE) (10) 

2 concerned (CONTINUE) 

3 slightly concerned, or (TERSVILINATE A1VD TALLU) 

4 not concerned (TEMINATE AND TfiL'LT) 1 2 3 4 5 6 7 8 9 10 (1 1-12) 

B. Have you ever done anything to help lower or maintain your cholesterol level? 

1 YES (CONTINUE) (13) 

2 NO (TERIWLINATE AND TALLU) 1 2 3 4 5 6 7 8 9 10 (14-15) 

Do you or does anyone in your household work ... 

In marketing research? 

h advertising or public relations? 

In the health care or medical field? 

For a store or company that markets or sells phamaceutical products? 

For a store in this shopping mall? 

IF YES TO OF THE ABOVE, 

TIEMINATEANDTALLY1 23456789 10 
D. During the past six months, have you padicipated in any market research survey other 

than a political poll? 

1 YES (TERMINATE AND TALLY) 1 2 3 4 5 6 7 8 9 10 (18-19) 

2 NO (CONTINUE) (20) 

E. Which of these groups includes your age? (READ LIST) 

1 Under 18 (TEMINATE AND TALLU) 1 2 3 4 5 6 7 8 9 10 (2 1-22) 

2 18-29 CHECK QUOTAS (23) 

3 30-44 

4 45-59 

5 60 and over CHECK QUOTAS 

6 mFUSED (TERMINATE AND TALLY) 1 2 3 4 5 6 7 8 9 1 0 (24-25) 

OVER QUOTA (TERMINATE AND TALLY) 1 2 3 4 5 6 7 8 9 10 (26-27) 

F. Do you usually wear eyeglasses or contact lenses when you read? 

1 YES (CONTINUE) (28) 

2 NO (ASK QN) 

6. Do you have your eyeglasses or contact lenses with you today? 

1 YES (CONTINUE) 

2 NO (TERMINATEANDTALLY)12345678910 

El. I'd like you to accompany me to the intemiewing area where I will show you some 

advertising matefials and then ask you some questions about it. We'll be giving you 

$2.00 to thank you for pafiicipating. I think that you'll find it interesting, and it will take 

only a few minutes. 

Before we continue, I need to obtain your name and telephone number. You may be 

contacted later to verify that the interview occurred, but infomation you provide will be 

kept confidential and will not be used to sell you anything. 

[IF AGmEABLE, ESCORT TO INTERVIEWING FACILITY. IF QUALIFIED 

BUT REFUSED, TERMINATE AND TALLY] 1 2 3 4 5 6 7 8 9 10 (32-33) 

I. =CORD (DO NOT ASK) 

1 MALE CHECK QUOTAS 

2 FEMALE CHECK QUOTAS 

Recruiter's Name: 

Interviewer's Name: 

Editor" Name: 
THIS PAGE WILL BE COMPLETED IN PEN IN FACILITY BEFOm 

INTERVIEW IS CONDUCTED. 

(mSCREEN RESPONDENT). 

PRINT NAME OF mSPONDENT: 

RECORD TELEPHONE NUMBER INCLUDING AREA CODE. 

DIAL TELEPHONE NUMBER TO MAm SURE IT IS A WO NG NUMBER 

AND THAT THE PHONE RINGS. 

(If number dialed is a non-working nurnber, terminate and tally by circling lSt 

availablenumber 1 2 3 4 5 6 7 8 9 10 (35-36) 

THIS SECTION MUST BE SIGNED BY PERSON WHO DIALED THE 

I certify that I dialed the number and that it is a working number. 

Name (PRINT): 

Signature: 

Date: