EPA ICR No. 2487.01; OMB Control No. 2070-NEW

ATTACHMENT B

Screening Questionnaire for “Leaning Green” 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 “Leaning Green” 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. When you select products for your household, such as cleaning products or personal care, how 

important is it to you to select products that can help protect the health of yourself, your family, 

or your pet? Please rate this on a scale from 1 to 5, where 1 is “not at all important” and 5 is 

“very important.”
TERMINATE >> 1 – Not at all important ____

TERMINATE >> 2 – Somewhat unimportant ____

TERMINATE >> 3 – No opinion either way ____

4 – Somewhat important____

TERMINATE >> 5 – Very important____

5. In the last three months, did you choose to buy a product over another because it was better for the 

environment?

Yes ____

No ____

6. If “Yes,” about how many times did you choose a product that was better for the environment? 

 

# of times ____ [MAX 1⁄2 > 3 TIMES]

7. How knowledgeable are you about environment issues (climate change, pollution...)? Please rate this 

on a scale from 1 to 4, where 1 is “not at all knowledgeable” and 4 is “very knowledgeable.”

TERMINATE >> 1 – Not at all knowledgeable ____

 2 – Not very knowledgeable ____

3 – Somewhat knowledgeable ____

TERMINATE >> 4 – Very knowledgeable____

8. How knowledgeable are you about selecting products that can help protect the environment? Please 

rate this on a scale from 1 to 4, where 1 is “not at all knowledgeable” and 4 is “very 

knowledgeable.”

TERMINATE >> 1 – Not at all knowledgeable ____

 2 – Not very knowledgeable ____

3 – Somewhat knowledgeable ____

TERMINATE >> 4 – Very knowledgeable____

9. Which of the following categories best describes your total annual household income? [GOOD MIX]

TERMINATE >> Under $15,000 _____

$15,000 - $24,999 _____

$25,000 - $34,999 _____

$35,000 - $54,999 _____

$55,000 - $74,999 _____

$75,000 - $100,000 _____

TERMINATE >> Over $100,000 _____

10. Please tell us your age. [Record age; GOOD MIX OF AGES 21+]

11. What is your current marital status? Are you ..... ?

Married or living with a partner_____

Single _____
Divorced _____

Widowed _____

12. 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 _____

13. 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 _____

14. [Record gender] [GOOD MIX]

Male _____

Female _____

15. 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 pets 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: ____________________