APPENDIX I:
SCREENING QUESTIONNAIRE
ISIS Research
The Boathouse
The Embankment
Putney
London
SW15 ILB
Tel: 020 8246 6200
Fax: 020 8246 6300
Job number
Resp No.
7
5
2
0
(1)
(2)
(3)
(4)
(5)
(6)
Card No.
(7)
0
1
(8)
(9)
Interviewer ID no.
(10)
(11)
(12)
(13)
Skip (14)(20)
Respondents to be recruited:
•
-
1500 passengers who are travelling long haul today
500 risk group 1
500 risk group 2
500 risk group 3
Good morning/afternoon, my name is ______ and I am conducting research on behalf of Isis
Research, who are an independent medical market research agency based in London. We
are currently undertaking a study on travel and health and would be very interested in your
opinions.
Would you be interested in participating in this research?
Before we go any further, I'd like to ask you some questions.
S1
Have you lived in the UK for 2 or more years?
(21)
Yes……..………… …………..………………………………………1 GO TO S2
No………… …………..…………………….. ……………………... 2 THANK & CLOSE
S2
Are you travelling long haul today, by which we mean a flight longer than 5 hours
duration?
INTERVIEWER: IF RESPONDENT’S FLIGHT IS BETWEEN 4 HRS 45 MINUTES
AND 5 HOURS THEN PLEASE CONTINUE TO S3. ANY LESS THAN THIS THEN
DO NOT CONTINUE.
(22)
Yes……..………… …………..………………………………………1 GO TO S3
No………… …………..…………………….. ……………………... 2 THANK & CLOSE
S3
Are you taking any medications, or being administered any medication by a physician
for a pre-existing medical condition?
(23)
Yes……..………… …………..………………………………………1 GO TO S4
No………… …………..…………………….. ……………………... 2 GO TO S5
S4
If ‘yes’ At S3, say: I AM GOING TO READ OUT A LIST MEDICATIONS. PLEASE
CAN YOU TELL ME IF YOU ARE TAKING ANY OF THESE FOR YOUR PREEXISTING MEDICAL CONDITION.
INERVIEWER: READ OUT UNDERLINED DRUGS IN LEFT-HAND COLUMN OF
TABLE BELOW AND CIRCLE APPROPRIATE RESPONSES IN ‘CODE’ COLUMN.
MULTICODE.
Drug
Use (for interviewer
guidance only)
Code
(24)
Aspirin
Anti-platelet
1
THANK & CLOSE
Heparin / anticoagulant / warfarin
Anti-coagulant
2
THANK & CLOSE
Beta blockers
Cardiac arrhythmias
(irregular heartbeat)/post
MI (heart attack)
3
CONTINUE TO S5
Ace inhibitors
Heart failure/post MI
(heart attack)
4
CONTINUE TO S5
Statins
(Crestor [rosuvastatin], Lescol [fluvastatin], Lipitor
[atorvastatin], Lipostat [ pravastatin], Zocor
[simvastatin]
High cholesterol/coronary
heart failure
5
CONTINUE TO S5
None of these
6
CONTINUE TO S5
Other
(if respondent mentions any other medication,
code as ‘other’)
7
CONTINUE TO S5
(alphaparin certoparin
arixtra fondaparinux sodium
calciparine calcium heparin
canusal heparin injection (heparin sodium)
ceprotin protein c
clexane enoxaparin
fragmin dalteparin sodium
hepsal heparin sodium injection
innohep tinzaparin
monoparin heparin sodium injection multiparin
heparin sodium injection phenindione
refludan lepirudin
sinthrome acenocoumaron
warfarin
xigris drotrecogin alfa
zibor bemiparin sodium)
S5
INTERVIEWER: HAND RESPONDENT THE SELF-COMPLETION
QUESTIONNAIRE AND
SAY:
Please could you now complete this short questionnaire, which asks you about
various aspects of your health. Please be assured that any information you
provide is totally confidential; by law we must comply with the data protection
act.
INTERVIEWER: TAKE BACK SELF-COMPLETION QUESTIONNAIRE FROM
RESPONDENT AND LABEL WITH RESPONDENT NUMBER.
CHECK WHETHER RESPONDENT HAS SPECIFIED THEIR AGE. IF NOT,
PLEASE ASK AGAIN WHETHER THEY MIND GIVING THEIR AGE. IF THEY
STILL REFUSE, PLEASE ASK S6 (OVERLEAF)
S6
Please could you tell me whether you are under 40 years or over 40 years of age?
INTERVIEWER: SINGLE CODE ONLY: PLEASE CIRCLE ONLY 1 RESPONSE
(25)
Under 40 years
1
40 years or over
2
INTERVIEWER: PLEASE NOW FILL IN THE CONFIDENTIAL ASSESSMENT OF
THE RESPONDENTS’ HEIGHT AND WHETHER THEY ARE CLASSED AS OW (S7
AND S8)
S7
Code respondent’s height from self-completion questionnaire
SINGLE CODE ONLY: PLEASE CIRCLE ONLY 1 RESPONSE
Males
(26)
Females
(27)
163 cm / 5ft 4in or shorter = S
1
150 cm / 4ft 11in or shorter = S
1
186 cm / 6ft 1in or taller = T
2
172 cm / 5ft 8in or taller = T
2
In between shortest and tallest heights =
A
S8
3
In between shortest and tallest heights =
A
Is respondent classed as OW?
I
INTERVIEWER: SEE WEIGHT BRACKETS ASSESSMENT CARD. IF
RESPONDENT FALLS WITHIN WEIGHT BRACKET SPECIFIED FOR THEIR
HEIGHT OR IS HEAVIER, THEN RESPONDENT IS CLASSED AS OW. IF
RESPONDENT IS LIGHTER THAN WEIGHT BRACKET SPECIFIED FOR THEIR
HEIGHT THEN THEY ARE NOT OW.
SINGLE CODE ONLY: PLEASE CIRCLE ONLY 1 RESPONSE.
(28)
OW
1
Not OW
2
3
NOW PLEASE CATEGORISE THE RESPONDENT ACCORDING TO THEIR RISK
GROUP. INTERVIEWER: CIRCLE 1 RISK GROUP ONLY
(29)
Risk Group 1
ALL OF THE FOLLOWING MUST APPLY:
1
RECRUIT
TO QUOTA
2
RECRUIT
TO QUOTA
‘No’ circled for all health status questions on self-completion
questionnaire
AND not T or S, i.e. A (code 3 @ S7)
AND not OW (code 2 @ S8)
AND under 40 years of age
Risk Group 2
AT LEAST ONE OF THE FOLLOWING MUST APPLY:
One or more of dark grey health status questions circled ‘yes’
OR aged 40 or over
OR T or S (code 1 or 2 @ S7)
OR OW (code 1 @ S8)
Risk Group 3
One or more of light grey health status questions circled ‘yes’
3
RECRUIT
TO QUOTA
Risk group 4
One or more of the white health status questions circled ‘yes’
4
THANK &
CLOSE
IF RESPONDENTS FALLS INTO RISK GROUPS 1, 2 OR 3 PROCEEED TO MAIN
QUESTIONNAIRE IF QUOTA NOT YET COMPLETE.
IF RESPONDENT FALLS INTO RISK GROUP 4, THANK & CLOSE.