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Eligibility Worksheet

Title: Health-Related Awareness with Age: A Focus Group

Investigators: Abigail Nehrkorn-Bailey, Ph.D., Department of Psychology; Joanna Morrissey, Ph.D., Department of Psychology

A research team at the University of Wisconsin-Green Bay (UWGB) is interested in learning about middle-aged and older adults' health-related awareness. We thank you for your interest in participating in a focus group discussion on this topic. In order for us to determine your eligibility as a focus group participant, we need to gather some information about you.

Please respond to the following questions in an honest way. This short questionnaire should take approximately 2 minutes to complete. After completing and submitting this short questionnaire, the research team will review your eligibility and contact you within 7 days to discuss the next steps. Thank you again for your interest!

If you have any questions, please feel free to contact Dr. Abigail Nehrkorn-Bailey at baileya@uwgb.edu or by phone at (920) 465-2136.

Full Name (First and Last)

Preferred Name

Date of Birth (mm/dd/yyyy)

What is your current age in years?

Sex

Male
Female
Other
Prefer not to say

Is English your primary language

No
Yes

Are you experiencing any major memory problems?

No
Yes

Are you willing to make a 1-hour time commitment to a focus group meeting?

No
Yes

Preferred Phone Number

E-mail Address

How did you hear about the focus group?

In general, are there certain days of the week that you would be available for a 1-hour focus group meeting?

In general, are there certain times of the day that you would be available for a focus group meeting?