OMB
No. 0910-xxxx
Exp. Date xx/xx/xxxx
Evaluation of the Public Education Campaign on Teen Tobacco- Adult (ExPECTT-A)
Subjects
for Questionnaire:
Study Screener
Section
A: Home Media Environment
Section B: Environment and
Demographics
Section C: Tobacco Use and Cessation
Section D: Youth Topics
STUDY INTRODUCTION
SCR1.
Hello, my name is (FI NAME) with RTI International in North Carolina. We are conducting a national study sponsored by the U.S. Food and Drug Administration’s Center for Tobacco Products.
[IF NOT ADDED DU] You should have received a letter explaining the study.
[IF NOT ADDED DU] HAND R COPY OF LETTER IF NEEDED
[IF ADDED DU] HAND R LEAD LETTER, ALLOW TIME TO READ
Next [GOTO SCR2]
SCR2. First, let me verify: do you live here?
1 YES
NO
DK
REF
[IF SCR2=YES]
SCR3. Are you 18 or older?
1 YES
2 NO
3 DK
4 REF
[IF SCR2=NO/DK/REF OR SCR3=NO/DK/REF]
SCR3a.
I need to speak with someone who is 18 or older and lives here. May I speak with someone who can help me?
1 YES, PERSON IS AVAILABLE
2 YES, BUT NEED TO SCHEDULE
3 NO, NO ONE LIVING HERE 18 OR OLDER
4 NODK
5 NOREF
PROGRAMMER: IF SCR3a=1 THEN SKIP BACK TO SCR1. IF SCR3a=2 THEN SEND USER TO SCR15 FOR SCHEDULING. IF SCR3a=3 THEN SKIP TO SCR17 VERIFICATION.
SCR4. ADDRESS VERIFICATION
First, I need to verify -- is this
STREET: (NUMBER AND STREET)
CITY: (CITY)
STATE: (STATE)
ZIP: (ZIP)
Address Is Correct [GOTO SCR5.]
Need to Edit Address [EDIT ADDRESS]
FI At Wrong Address [BREAKOFF SELECT CORRECT CASE]
SCR4a.
EDIT ADDRESS [IF ADDRESS VERIFICATION = NEED TO EDIT ADDRESS]
TOUCH THE ITEM YOU NEED TO EDIT
STREET # (NUMBER)
STREET: (STREET)
CITY: (CITY)
STATE: (STATE)
ZIP: (ZIP)
Update [SAVE UPDATED ADDRESS, THEN GOTO SCR5]
SCR5.
STUDY DESCRIPTION
GIVE PERSON STUDY DESCRIPTION AND SAY
I’d like you to follow along with me as I read the following statement. It describes the survey and assures the privacy to the fullest extent allowable by lawof any information you provide. It also explains that your answers are used for statistical purposes only and that your participation is voluntary.
INTERVIEW READ THE STUDY DESCRIPTION TO THE PERSON
I have some questions about people living here that will take a few minutes to complete. The screening questions will determine if anyone in your household is eligible to participate in the full interview. We are looking for and interviewing youth between the ages of 11-16 in order to understand their attitudes and beliefs towards tobacco use as well as their media use. If any youth in your household meets these criteria and completes the full interview, we will offer them an incentive of $20 in cash after the interview is completed.
Next [SCR6]
SCR6.
FOR REGULAR HUs SUCH AS INDIVIDUAL HOUSES, TOWNHOUSES, DUPLEXES, TRAILERS, COTTAGES
Before we begin, are there any other living quarters within this structure or on this property, such as a separate apartment with a separate entrance?
1 YES
2 NO
3 DK
4 REF
Yes [SCR6a] No [SCR7]
[IF MISSED DU: CANNOT ADD UNIT
“YOU CANNOT ADD A MISSED DU
FROM A DU THAT HAS BEEN ADDED”
MISSED DUs]
SCR6a.
RECORD STREET ADDRESS OR DESCRIPTION OF UNIT
STREET #:
STREET:
SAVE[OCCUPANCY] Cancel [CANCEL DU: “ARE YOU SURE
YOU WANT TO CANCEL ADDITION OF THIS DU? IF Yes, OCCUPANCY. IF No, MISSED DU ADDRESS.]
SCR7.
TOTAL SDU MEMBERS
(Including yourself), how many people usually live in this household?
ENTER NUMBER 1-20
[IF TOTAL SDU MEMBERS = 1, ONLY HOUSEHOLD MEMBER: “CONFIRM RESPONSE: IS THERE ONLY 1 PERSON IN THIS HOUSEHOLD?” IF No,TOTAL SDU MEMBERS. IF Yes, GOTO SCR17 VERIFICATION.
IF SCR7 = 0 , ???
IF SCR7 = 1 , GOTO SCR7_CONFRM
SCR7_CONFRM
IS THERE ONLY 1 PERSON IN THIS HOUSEHOLD?
1 YES
2 NO
IF SCR7_CONFRM = 1, GOTO SCR17
IF SCR7_CONFRM = 2, GO BACK TO SCR7 TO CORRECT
SCR7a.
How many youth ages 11 to 16 live here now?
_____( range 0-9]
DK/REF
PROGRAMMER:
IF SCR7a = 1, GO TO SCR8
IF SCR7a = 2-9, GO TO SCR8a LOOP Series
IF SCR7a=0, SKIP TO SCR17 VERIFICATION
IF SCR7a = DK or REF SKIP TO SCR7b
SCR7b. I’m sorry but I’m unable to determine whether anyone in your household is eligible. Is there someone else who lives in this household that I can speak with?
1 YES
2 YES, BUT NEED TO SCHEDULE
3 NO
DK/REF
PROGRAMMER: IF SCR7b = 1 GO BACK TO SCR1. IF SCR7b = 2 THEN SKIP TO SCR15. IF SCR7b = 3 DK REF SKIP TO SCR18.
IF SCR7a = 1
SCR8a.
YOUTH ROSTER INTRO
Please tell me the first name or nickname of the youth between 11 and 16 years of age, and his or her age?
(ASK IF NOT OBVIOUS: Is this person male or female?)
SCR 8a1
<NAME>__________ [ALLOW 20 CHARACTERS]
SCR8a2
<Age>_____( range 11-16)
DK/REF
SCR8a3
<Gender>
1 Male
2 Female
PROGRAMMER: GOTO SCR9
IF SCR7a > 1
LOOP STARTS
SCR8b:
Next I'll ask a few questions about the youth who live here. Let's start with the oldest child between the ages of 11 to 16 and then continue with the next oldest child.
What is the oldest /[the next] child’s first name or nickname and age?
(ASK IF NOT OBVIOUS: Is this person male or female?)
Note: [the next] is used starting with the second loop
SCR8b1
<NAME>__________ [ALLOW 20 CHARACTERS]
NODK
NOREF
SCR8b2
<Age>_____( range 11-16)
DK/REF
SCR8b3
<Gender>
1 Male
2 Female
PROGRAMMER:
RECORD NAME, AGE, AND GENDER IN SCR8 AND SCR8a FOR SCR7a TIMES (ONCE FOR EACH CHILD REPORTED IN SCR7a).
PROGRAMMER: GOTO SCR10
SCR9.
ONE ELIGIBLE YOUTH
Thank you. It turns out that [IF SCR7a = 1 FILL SCR8a1 <NAME>] is eligible for the survey. The survey will collect data from youth in order to understand attitudes and beliefs toward tobacco use, as well as youth media use.
In order to proceed, I need to speak with the parent or legal guardian of [PROGRAMMER: INSERT SCR8a1 <NAME>].
PRESS 1 TO CONTINUE.
SCR9a.
What is the first name or nickname of the parent of legal guardian of [PROGRAMMER INSERT SCR8a1 <NAME>].
<LG_NAME>__________ [ALLOW 20 CHARACTERS]
DK/REF
PROGRAMMER: IF SCR9a = DK/REF, SKIP TO SCR15.
SCR9b.
(Would that be you?)
1 YES
2 NO
3 DK
4 REF
IF SCR9b = YES SKIP TO SCR 12.
IF SCR9b = NO SKIP TO SCR13.
SCR10.
MORE THAN ONE ELIGIBLE YOUTH
IF SCR7a>1
Thank you. It turns out that [IF SCR7a > 1, FILL SCR8b1 LOOP <NAMES>] are eligible for the survey. The survey will collect data from youth in order to understand attitudes and beliefs towards tobacco use, as well as youth media use.
In order to proceed, I need to speak with the parent or legal guardian of [FILL SCR8b1 series LOOP <NAMES>].
GOTO SCR10a
SCR10a.
Do [FILL CHILD NAMES FROM SCR8b1 LOOP] have the same parent or legal guardian?
1 YES
2 NO
3 DK
4 REF
IF SCR10a = YES, GOTO SCR10b.
IF SCR10a = NO, GOTO SCR11
IF SCR10a = DK/REF, SKIP TO SCR15.
SCR10b.
What is the first name or nickname of the parent and legal guardian of [PROGRAMMER: INSERT CHILD NAMES FROM SCR8b1 SERIES]
<LG_NAME>__________ [ALLOW 20 CHARACTERS]
DK/REF
SCR10c.
(Would that be you?)
1 YES
2 NO
IF SCR10c = YES, GOTO SCR12
IF SCR10c = NO, GOTO SCR13
SCR11.
LOOP SERIES
Please tell me the first name or nickname of [FILL FIRST CHILD NAME COLLECTED IN SCR8b1 SERIES]’s parent or legal guardian.
SCR11_1
<LG_NAME>__________ [ALLOW 20 CHARACTERS]
DK/REF
SCR11a.
(Would that be you?)
1 YES
2 NO
IF SCR11a = YES, GOTO SCR12
IF SCR11a = NO, GOTO SCR13
SCR12.
[IF SCR9b = YES, IF SCR10c = YES, IF ANY SCR11 LOOP = YES] I’d like to explain more about this study and how you may be able to help us. If this is a good time, we could get started now. I will need a place to set up a laptop computer.
1 YES
2 NOT NOW, BUT LATER
3 NO, REFUSAL TO INTERVIEW
NODK
NOREF
PROGRAMMER: IF SCR12=1 THEN SKIP TO SCRFINISH AND CODE AS ELIGIBLE, READY-FOR-CONSENT. IF SCR12=2 THEN SKIP TO SCR15 SCHEDULER. IF SCR12=3, SKIP TO SCR16 REFUSAL.
SCR13.
[IF SCR9b = NO, IF SCR10c = NO AND ALL SCR11b LOOP = NO] May I speak with [FILL: CHILD NAME]’s parent or guardian?
1 YES
2 NOT NOW, BUT LATER
3 NO, REFUSAL TO INTERVIEW
4 NODK
5 NOREF
PROGRAMMER: IF SCR13 = 2 THEN SKIP TO SCR15 SCHEDULER, IF SCR13=3 THEN SKIP TO SCR16 REFUSAL
SCR14.
[IF SCR13=YES] [ONCE PARENT/GUARDIAN IS AVAILABLE] Hello, my name is [INTERVIEWER NAME] from RTI International in North Carolina. We are conducting a national study of youth in order to understand attitudes and beliefs toward tobacco use, as well as youth media use. Based on answers to the screening questions, [IF SC7 =1 your child has] [IF SCR >1 your children have] been selected for the interview. I’d like to explain the study and how you may be able to help us. If this is a good time, we could get started. I have some information for you about the study and I will need a place to set up a laptop computer.
1 YES
2 NOT NOW, BUT LATER
3, NO, REFUSAL TO INTERVIEW
4 NODK
5 NOREF
PROGRAMMER: IF SCR14=1 THEN SKIP TO SCRFINISH AND CODE AS SC Completed – Child Selected (ExPECTT RESULT CODE 31 or 32), READY-FOR-CONSENT. IF SCR14=3, SKIP TO SCR16 REFUSAL.
[IF SCR12=2 OR SCR13=2 OR SCR14=2]
SCR15.
Let me schedule a convenient time to come back. First what would be a good date?
ENTER MONTH AND DAY HERE; ENTER TIME ON THE NEXT THREE SCREENS.
MONTH
DK/REF
DAY
DK/REF
[IF SCR12=2 OR SCR13=2 OR SCR14=2]
SCR15a. (Let me schedule a convenient time to come back.) What would be a good time on [FILL SCR15 DATE]?
ENTER HOUR (1-12) HERE; ENTER MINUTES ON NEXT SCREEN.
HOUR
DK/REF
[IF SCR12=2 OR SCR13=2 OR SCR14=2]
SCR15b. (Let me schedule a convenient time to come back. What would be a good time on [FILL SCR15 DATE])?
ENTER MINUTES HERE.
DK/REF
[IF SCR12=2 OR SCR13=2 OR SCR14=2]
SCR15c.
ENTER AM OR PM
DK/REF
[IF SCR12=2 OR SCR13=2 OR SCR14=2].
SCR15d. Thank you for setting an appointment for the interview/ IF SCR3a=2, me to return to complete the brief screening questions]. I will return on [FILL SCR15 MONTH] [FILL SCR15 DAY] at [FILL SCR15a HOUR]:[FILL SCR15b MINUTE] [FILL SCR15c AM OR PM].
PROGRAMMER: UPON COMPLETING SCR15a-d, SKIP TO SCRFINISH
[IF SCR12=3 OR SCR13=3 OR SCR14=3 OR SCR3a=REF]
SCR16.
Thank you for your time and consideration. I have just a few more questions if you can spare just a couple more minutes. Can you tell me more about your reasons for not participating in this study?
___________________ [ALLOW 100 CHARACTERS]
DK/REF
[IF SCR3a=3, NO ADULT LIVING HERE OR SCR7a= 0]
SCR17
I’m sorry, but based on your answers to the screening questions no one in your household is eligible to participate in this study. Thank you for taking the time to answer these screening questions. So that my supervisor may check the quality of my work, please give me just your first name and telephone number.
IF THE SR REFUSES TO ANSWER, ENTER 99
<FIRST NAME> _________ [ALLOW 20 CHARACTERS]
DK/REF
<TELEPHONE NUMBER> ___________ (APPLY 3-3-4 FORMAT)
DK/REF
SCR18. Those are all the questions I have. Thank you for your assistance.
INTERVIEWER: THE REMAINING 2 QUESTIONS ARE TO BE RECORDED BY OBSERVATION.
PRESS NEXT TO CONTINUE
SCR19. INTERVIEWER RECORD SCREENING RESPONDENT’S GENDER
1 MALE
2 FEMALE
SCR20. [PROGRAMMER: ALL SCREENINGS WILL ANSWER] INTERVIEWER RECORD PRIMARY LANGUAGE USED FOR THIS SCREENING
1 ENGLISH
2 SPANISH
SCRFINISH
TAP “EXIT” TO EXIT TO CASE MANAGEMENT SYSTEM (CMS) OR “BACK” TO GO BACK.
PRESS 1 TO EXIT SCREENER
Section A: Home Media Environment
A1. How many of the following items are there in your home? [INSERT PHOTOS]
|
0 Items |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 or more items |
99 |
A1_1. TVs? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_2. DVD or VCR players? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_3. Digital TV recorders such as TiVo or other DVR? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_4. Access to paid streaming services such as Netflix or Hulu Plus? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_5. Access to streaming video boxes like Roku or Apple TV? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_6. Access to premium channels such as HBO or Showtime? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_7. Tablet computers like an iPad, Samsung Galaxy, Motorola Xoom, or Kindle Fire? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_7a. (ASK IF A2_8 >0) How many of your (INSERT #) tablets have internet access? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_8. Other computers or laptops? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_8a. (ASK IF A2_7 >0) How many of your (INSERT #) computers or laptops have internet access? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_9. Ipods or other MP3 players, CD players, radios? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_10. Video game players that hook up to TV (Xbox, Wii, PSP) and handheld players (Nintendo DS, Sony PSP, iPod) |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A2. Is a TV usually kept on in your home, even when no one is watching?
1 Yes, we usually keep a TV on.
2 No, we do not keep a TV on.
9 Prefer not to answer
A3. In your home, is the TV usually on during meals, or not?
1 Yes, the TV is usually on during meals.
2 No, the TV is not usually on during meals.
9 Prefer not to answer
A4. During the past 7 days, how many meals did all or most of your family sit down and eat together at home?”
_______ Number of days
9 Prefer not to answer
Section B: Demographics
B1. What is your age?
_______ years old
9 Prefer not to answer
B2 How many children aged 17 or younger live in your household 6 months or more of the year?
_______ Number of Children
9 Prefer not to answer
B3 Are you Hispanic, Latino/a, or of Spanish origin?
1 No, not of Hispanic, Latino/a, or Spanish origin
2 Yes, Mexican American, Chicano/a
3 Yes, Puerto Rican
4 Yes, Cuban
5 Yes, another Hispanic, Latino/a, or Spanish origin
9 Prefer not to answer
B4 What race or races do you consider yourself to be? Please select 1 or more of these categories.
|
1 |
|
|
B4_1. White |
1 |
|
|
B4_2. Black or African American |
1 |
|
|
B4_3. American Indian or Alaska Native |
1 |
|
|
B4_4. Asian Indian |
1 |
|
|
B4_5. Chinese |
1 |
|
|
B4_6. Filipino |
1 |
|
|
B4_7. Japanese |
1 |
|
|
B4_8. Korean |
1 |
|
|
B4_9. Vietnamese |
1 |
|
|
B4_10. Native Hawaiian |
1 |
|
|
B4_11. Guamanian or Chamorro |
1 |
|
|
B4_12. Samoan |
1 |
|
|
B4_13. Other Asian |
1 |
|
|
B4_14. Other Pacific Islander |
1 |
|
|
|
|
|
|
B5. What is the highest grade or level of schooling you completed?
1 5th grade or less
2 6th grade
3 7th grade
4 8th grade
5 9th grade
6 10th grade
7 11th grade
8 12th grade, no diploma
9 GED or equivalent
10 High school diploma
11 Some college, no degree
12 Certificate, diploma, or associate degree: occupational, technical, or vocational program
13 Associate degree: academic program
14 Bachelor’s degree
15 Master’s degree
16 Professional school degree (examples: ND, DDS, DVM, LLB, JD)
17 Doctoral degree (examples: PhD, Edd)
99 Prefer not to answer
The next question is about the total income of YOUR HOUSEHOLD for the PAST 12 MONTHS. Please include your income PLUS the income of all members living in your household (including cohabiting partners and armed forces members living at home). Please count income BEFORE TAXES and from all sources (such as wages, salaries, tips, net income from a business, interest, dividends, child support, alimony, and Social Security, public assistance, pensions, or retirement benefits).
B6. Thinking about members of your family living in this household, what is your combined annual income, meaning the total pre-tax income from all sources earned in the past year?
1 $0 to $9,999
2 $10,000 to $14,999
3 $15,000 to $19,999
4 $20,000 to $34,999
5 $35,000 to $49,999
6 $50,000 to $74,999
7 $75,000 to $99,999
8 $100,000 to $199,999
9 $200,000 or more
99 Prefer not to answer
B7. Are you now …?
1 Married
2 Living with a partner
3 Divorced
4 Widowed
5 Separated
6 Single, that is, never married and not now living with a partner
9 Prefer not to answer
B8. Which statement best describes your current employment status?
1 Working full time as a paid employee
2 Working full time, self-employed
3 Not working, on temporary layoff from a job
4 Not working, looking for work
5 Not working, retired
6 Not working, disabled
7 Not working, other
9 Prefer not to answer
B9. Do you currently own or rent your home?
1 Rent
2 Own
99 Prefer not to answer
Section C: Tobacco Use and Cessation
C1. About how many cigarettes have you smoked in your entire life? Your best guess is fine.
1 1 or more puffs, but never a whole cigarette [GO TO C1a]
2 1 cigarette
3 2 to 5 cigarettes
4 6 to 15 cigarettes (about half a pack)
5 16 to 25 cigarettes (about a pack)
6 26 to 99 cigarettes (more than a pack but less than 5 packs)
7 100 or more cigarettes (5 or more packs)
9 Prefer not to answer
C1a. Do you now smoke every day, some days, or not at all?
1 I smoke every day
2 I smoke on some days
3 I do not smoke at all
9 Prefer not to answer
C2. About how long has it been since you last smoked cigarettes—even a puff?
|_|_| Hours [RANGE: 0–23]
|_| Days [RANGE: 0–6]
|_|_| Weeks [RANGE: 0–3]
|_|_| Months [RANGE: 0–11]
|_|_| Years [RANGE: 0–97]
1 I have never tried cigarette smoking, even one or two puffs.
9 Prefer not to answer
C3. On the average, about how many cigarettes a day do you now smoke?
Please enter the number of cigarettes below. You can use the chart below, which tells you how many cigarettes are in a pack.
¼ PACK = 5 1-1/4 PACKS = 25 2-1/4 PACKS = 45
½ PACK = 10 1-1/2 PACKS = 30 2-1/2 PACKS = 50
¾ PACK = 15 1-3/4 PACKS = 35 2-3/4 PACKS = 55
1 PACK = 20 2 PACKS = 40 3 PACKS = 60
______ Number of cigarettes
9 Prefer not to answer
C4. On the days that you smoke, how soon after you wake up do you usually have your first cigarette? Would you say…
1 Within 5 minutes
2 6–30 minutes
3 From more than 30 minutes to 1 hour
4 After more than 1 hour
9 Prefer not to answer
C5. During the past 3 months, did you stop smoking for one day or longer because you were trying to quit smoking cigarettes for good?
1 Yes
2 No
9 Prefer not to answer
The next questions are about the use of tobacco other than cigarettes.
C6. Have you ever used smokeless tobacco, smokeless tobacco, such as chewing tobacco, snuff, or dip?
1 Yes
2 No
9 Prefer not to answer
C7. Do you now use smokeless tobacco, such as chewing tobacco, snuff, or dip, every day, some days, or not at all?
1 I use smokeless tobacco every day
2 I use smokeless tobacco on some days
3 I do not use smokeless tobacco at all
9 Prefer not to answer
C8. On the days that you use smokeless tobacco, such as chewing tobacco, snuff, or dip, how soon after you wake up do you usually use it? Would you say…
1 Within 5 minutes
2 6–30 minutes
3 From more than 30 minutes to 1 hour
4 After more than 1 hour
9 Prefer not to answer
C9. Do you.…
|
1 |
2 |
9 |
C9_1 Smoke cigars, cigarillos, or little cigars? |
1 |
2 |
9 |
C9_2 Use any other form of tobacco? (if yes, specify) |
1 |
2 |
9 |
C10. Among close friends, do….
1 All of them smoke?
2 Most of them smoke?
3 Most of them not smoke?
4 None of them smoke?
9 Prefer not to answer
C11. Among close relatives, do…
1 All of them smoke?
2 Most of them smoke?
3 Most of them not smoke?
4 None of them smoke?
9 Prefer not to answer
C12. Other than you, have any adults in your household used any of the following during the past 30 days…? (You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
1 cigarettes
2 smokeless tobacco, such as chewing tobacco, snuff, snus (rhymes with goose) or dip, such as Copenhagen, Skoal, Grizzly, Kodiak, and Red Seal
3 cigars, cigarillos, or little cigars such as Swisher Sweets, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s
4 any other form of tobacco
6 No, no one who lives with me has used any form of tobacco during the past 30 days
9 Prefer not to answer
C13. To the best of your knowledge, has your child [YOUTH NAME] used any of the following during the past 30 days…? (You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
1 cigarettes
2 smokeless tobacco, such as chewing tobacco, snuff, snus (rhymes with goose) or dip, such as Copenhagen, Skoal, Grizzly, Kodiak, and Red Seal
3 cigars, cigarillos, or little cigars such as Swisher Sweets, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s
4 any other form of tobacco
6 No, [YOUTH NAME] has not used any form of tobacco during the past 30 days
9 Prefer not to answer
C14. Which statement best describes the rules about smoking in your home? Would you say…
1 Smoking is not allowed anywhere inside your home
2 Smoking is allowed in some places or at some times
3 Smoking is allowed anywhere inside the home
4 There are no rules about smoking inside the home
9 Prefer not to answer
Section D: Youth Topics
D1. Does [YOUTH NAME] have a cell phone?
1 Yes, [YOUTH NAME] has (his/her) own cell phone
2 Yes, [YOUTH NAME] shares a phone or uses someone else’s in our home
3 No, [YOUTH NAME] does not own or use a cell phone.
9 Prefer not to answer
(ASK if A1 = 1 or 2)
D2. Some cell phones are called 'smartphones' because of certain features they have. Is [YOUTH NAME]’s cell phone a smartphone, such as an iPhone or Android?
1 Yes
2 No
3 I don’t know
9 Prefer not to answer
D3. Which of these best describes where [YOUTH NAME] sleeps at night?
1 In a bedroom of (his/her) own
2 In a bedroom [HE/SHE] shares with someone else
2 In another room, specify______________
9 Prefer not to answer
(IF D1 = 1 or 2, AND A1_1 to A4_10 > 0, ASK CORRESPONDING FOLLOW-UP ITEM A5_1 TO A_10)
D4_1—D4_10. Does [YOUTH NAME 1] have (INSERT A1_1 to A1_10) in (his/her) bedroom?
1 yes
2 no
2 I don’t know
9 Prefer not to answer
The next questions are about your relationship in general with [YOUTH NAME].
D5a. In the past 30 days, how many times have you done the following things with [YOUTH NAME]?
|
1 At least once a week |
2 At least once a month |
3 Less Often |
4 Never |
5 |
9 |
D5_1. Gone shopping? |
1 |
2 |
3 |
4 |
5 |
9 |
D5_2. Gone to a movie, sport event, concert, play, or museum? |
1 |
2 |
3 |
4 |
5 |
9 |
D5_3. Watched an entire television show together? |
1 |
2 |
3 |
4 |
5 |
9 |
D5b. For the following list of activities, indicate whether this is something you and [YOUTH NAME] do together at least once a week, at least once a month, less often, or never. How often do you. . .
|
1 At least once a week |
2 At least once a month |
3 Less Often |
4 Never |
5 |
9 |
D5_1. Go to religious services or other religious activities together? |
1 |
2 |
3 |
4 |
5 |
9 |
D5_2. Do homework or school projects when school is in session |
1 |
2 |
3 |
4 |
5 |
9 |
D5_3. Attend a party or a family gathering together? |
1 |
2 |
3 |
4 |
5 |
9 |
D5_4. Do volunteer work together to help other people or improve your neighborhood? |
1 |
2 |
3 |
4 |
5 |
9 |
D5_5. Play a game or sport together? |
1 |
2 |
3 |
4 |
5 |
9 |
D5c. Please tell me how often you do each of the following?
How often do you….. |
1 Often |
2 Some-times |
3 Rarely |
4 Never |
5 |
9 |
D5c_1. make [YOUTH NAME] feel better when [HE/SHE] is upset? |
1 |
2 |
3 |
4 |
5 |
9 |
D5c_2. Tell [YOUTH NAME] when [HE/SHE] does a good job on things. |
1 |
2 |
3 |
4 |
5 |
9 |
D5c_3. Want to hear about his/her problems. |
1 |
2 |
3 |
4 |
5 |
9 |
D5c_4. Tell [YOUTH NAME] times when [HE/SHE] must come home. |
1 |
2 |
3 |
4 |
5 |
9 |
D5c_5. Have rules that [YOUTH NAME] must follow. |
1 |
2 |
3 |
4 |
5 |
9 |
D5c_6. Make sure [YOUTH NAME] doesn’t stay up too late. |
1 |
2 |
3 |
4 |
5 |
9 |
D5c_7. Monitor what [YOUTH NAME] watches on TV. |
1 |
2 |
3 |
4 |
5 |
9 |
D5c_8. Put restrictions on the music [YOUTH NAME] listens to or videogames [HE/SHE] can play |
1 |
2 |
3 |
4 |
5 |
9 |
D5c_9. Give [YOUTH NAME] chores around the house that [HE/SHE] is responsible for doing. |
1 |
2 |
3 |
4 |
5 |
9 |
D6. Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statement.
I am satisfied are with the way [YOUTH NAME] and I communicate with each other.
Would you say you…
1 Strongly Disagree
2 Disagree
3 Neither agree nor disagree (neutral)
4 Agree
5 Strongly Agree
9 Prefer not to answer
D7. How close do you feel to [YOUTH NAME]?
1 Not at all close
2 Not very close
3 Somewhat close
4 Quite close
5 Very close
9 Prefer not to answer
D8. Have you ever talked to [YOUTH NAME] about reasons for not smoking cigarettes or using other types of tobacco like cigars and chewing tobacco?
1 Yes
2 No
9 Prefer not to answer
Thank you for taking time to complete this survey.
OMB No: 0910-xxxx Expiration Date: xx/xx/xxxx
Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 10 minutes per response. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to PRAStaff@fda.hhs.gov
| File Type | application/msword |
| File Modified | 2013-10-29 |
| File Created | 2013-10-28 |