Online Screening Instrument for Youth

Attachment H: Online Survey Screening Instrument for Youth

Form Approved

OMB No. __0920-XXX__

Exp. Date _xx/xx/20xx_

Public Reporting burden of this collection of information is estimated at 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency many not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-XXXX).

Online Survey Screening Instrument for Youth

Your parent or guardian has answered some background questions, and now we’d like to ask you a few questions too. These questions will only take a few moments to answer.

1. What grade are you in?

( ) 6^th grade Continue

( ) 7^th grade Continue

( ) 8^th grade Continue

( ) Other Terminate

Selection must match parent’s response.

2. How old are you?

( ) 11 Continue

( ) 12 Continue

( ) 13 Continue

( ) 14 Continue

( ) Other Terminate

Selection must match parent’s response.

2. Are you a boy or girl?

( ) Boy Continue

( ) Girl Continue

Selection must match parent’s response.

2. How do you like to spend your free time? Check all that apply.

( ) Intellectual activities, such as reading, writing, doing homework, etc. Continue

( ) Creative activities, such as doing crafts, sewing, painting, etc Continue

( ) Social activities, such as hanging out with friends, talking on the phone, dating, etc.

Continue

( ) Physical activities, such as playing sports, working out at the gym, etc. Continue

( ) Community activities, such as going to religious functions, volunteer work, etc.

Continue

Recruit a mix of primary respondents who spend their time in different ways.

Please click on the following link to be redirected to a secure Web site where you will have the opportunity to either provide or decline assent to participate. Upon providing assent to participate in the study, you will be redirected to a secure Web site to complete the survey. It should take approximately 10 minutes to answer the survey questions.

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