Att S

NOTICE: Public reporting burden (or time) for this collection of information is estimated to average 4 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, Paperwork Reduction Project (0930-0110); Room 2-1057; 1
Choke Cherry Road, Rockville, MD 20857. An agency may 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. The OMB control number for this project is 0930-0110.

RESIDENT
[ADDRESS]

OMB No.: 0930-0110
OMB Expiration Date:
xx/xx/xx

[DATE]

RTI has been conducting a nationwide survey for the United States Public Health Service on tobacco, alcohol, drug
use and other health-related issues. Our records indicate that a [AGE] year old [GENDER] in your household was
interviewed. We would appreciate it if [HE/SHE] would take a moment to complete the following questions about
[HIS/HER] experience.
This information is only used to verify the quality of our interviewer’s performance.
1. Were you interviewed in-person or over the telephone?
In-person ___ Over the telephone___
2. Did the interviewer provide you with a laptop computer for you to enter some of your responses?
Yes___
No___
Please explain:_________________________________________________________________
3. Did you complete a computer practice session that showed you how to enter your responses in the computer?
Yes___ No___
4. Did you have the option of listening to the questions through a set of headphones?
Yes___ No___
5. Were you paid for your participation?
Yes___ No___
If yes, how much were you paid? $_____
6. Was the interviewer professional and courteous?
Yes___
No___
Please describe how our interviewer could improve his/her behavior: _____________________
__________________________________________________________________________________________
__________________________________________________________________________________________

A stamped, pre-addressed envelope is enclosed for your convenience in returning this form. Thank you for your
cooperation.
Sincerely,

Ilona S. Johnson
National Field Director