Screening Questionnaire - Word

SCREENING QUESTIONNAIRE

Form Approved

OMB No. 0920-0923

Exp. Date XX/XX/20XX

Evaluation of the National Tobacco Prevention and Control Public Education Screening Questionnaire

Public reporting burden of this collection of information is estimated to average 5 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 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. 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, Georgia 30333; ATTN: PRA (0920-0923).

PREFER_LANG. ¿Prefiere contestar la encuesta en español o en inglés?

Do you prefer to do surveys in Spanish or English?

Español 1

English 2

[IF PREFER_LANG=“ESPANOL”, SHOW SPANISH VERSION OF THE SURVEY]

[IF PREFER_LANG=“ENGLISH” OR REFUSED, SHOW ENGLISH VERSION OF THE SURVEY]

Show KP_S1 if Sample = KP.

[Display]

KP_S1. Welcome to the CDC Health Survey 2014! Your opinion counts!

Please try to answer all questions to the best of your ability. Your answers will be kept private.

We have a few qualifying questions about you and other members of your household.

If you are selected and complete our 30-minute interview, you'll receive 15,000 bonus points credited to your KnowledgePanel account as our way of saying “thank you.”

Show ABS_S1 to ABS_NQRACE2 if Sample = ABS.

ABS_S1.Welcome to the CDC Health Survey 2014! Your opinion counts!

Please try to answer all questions to the best of your ability. Your answers will be kept private.

We have a few qualifying questions about you and other members of your household.

If you are selected and complete our 30-minute interview, you'll be sent $20 as our way of saying “thank you.”

First, are you currently 18 years old or older?

Yes 1

No 2

Terminate if ABS_S1 refused after prompt.

[show if ABS_S1 = 2; prompt once]

ABS_S1a. We will need to have this survey completed by someone who is 18 years old or older from your household, can you have a person who is 18 or older from your household complete this survey?

Yes [RE-ASK ABS_S1] 1

No [THANK AND TERMINATE] 2

[Show ABS_S3a (number box with range 18-120) and ABD_S3b (SP) on the same screen]

Our first few questions are primarily for classification purposes and they enable us to select the questions to ask you later in the survey. They will also help us properly analyze responses to this survey.

ABS_S3a. How old are you (in years)? ______ years old

ABS_S3b. Are you…?

Male 1

Female 2

Terminate if ABS_S3a < 18.

Recode ABS_S3a and ABS_S3b values into PPAGE and PPGENDER.

ABS_NQRACE1. This is about Hispanic ethnicity. Are you of Spanish, Hispanic, or Latino descent?

No, I am not [SP] 1

Yes, Mexican, Mexican American, Chicano 2

Yes, Puerto Rican 3

Yes, Cuban 4

Yes, Central American 5

Yes, South American 6

Yes, Caribbean 7

Yes, Other Spanish/Hispanic/Latino 8

ABS_NQRACE2. Please choose one or more races that you consider yourself to be.

White 1

Black or African American 2

American Indian or Alaska Native 3

Asian 4

Native Hawaiian or Other Pacific Islander 5

ALL_G1619. Would you say that you can…?

Very well

Pretty well

Just a little

Not at all

Carry on a conversation in Spanish, both understanding and speaking

Read a newspaper or book in Spanish

Carry on a conversation in English, both understanding and speaking

Read a newspaper or book in English

Show ABS_G20 if Sample = ABS.

ABS_G20. Do you or anyone in this household connect to the Internet from home?

Yes 1

No 2

[if ABS_G20 = 1 or PPNET = 1]

ALL_G20a. What type of Internet connection do you most often use at home to connect to the Internet?  Is it…?

Dial-up connection through the telephone 1

Wired with a high speed connection (cable, fiber optic, satellite, DSL, etc.) 2

Wireless connection with a desktop computer, laptop, or tablet 3

Wireless connection with a cell phone or smart phone 4

Not at all sure 5

I personally cannot access the Internet at home 6

ALL_G20b. What type of Internet connection are you currently using to take this survey?

Dial-up connection through the telephone 1

Wired with a high speed connection (cable, fiber optic, satellite, DSL, etc.) 2

Wireless connection with a desktop computer, laptop, or tablet 3

Wireless connection with a cell phone or smart phone 4

Not at all sure 5

ALL_G12. In which state do you live?

_________Pull Down List of States

[Dropdown; BASED ON THE STATE SELECTED IN ALL_G12, SHOW COUNTIES]

ALL_G13. What county do you live in?

_________Pull Down List of Counties

ALL_G14. In what zip code do you live?

Terminate if ALL_G14 refused after prompt.

ALL_G14a. You told us you live in zip code [show zip code from ALL_G14].  Is this correct?

Yes 1

No 2

[If ALL_G14a = “No” or refused after prompt, show ALL_G14 again.  Record most current zip code entered.]

CREATE DOV_DMA (000-999) BASED ON THE ZIP CODE ENTERED IN ALL_G14. SHOW DOV_DMA VALUE DURING TESTING.

ALL_S3c. Have you smoked at least 100 cigarettes in your entire lifetime?

Yes 1

No 2

Terminate if ALL_S3c refused after prompt.

ALL_S3d. Do you now smoke every day, some days, or not at all?

Every day 1

Some days 2

Not at all 3

Terminate if ALL_S3d refused after prompt.

ALL_S2. Including yourself, how many adults 18 or older are currently living in your household?

1 1

2 2

3 3

4 4

5 or more 5

None, no adults live here 6

Terminate if ALL_S2 = “None, no adults live here” or refused after prompt.

Show All_S4 if ALL_S2>1.

ALL_S4. Next, we’d like some brief information about [IF ALL_S2=2: the other adult / IF ALL_S2=3-5: each of the other adults] in the household. For each adult other than you, please answer the following questions.

[POPULATE AS MANY ROWS AS NUMBER OF ADULTS INDICATED AT ALL_S2, WITH MAX OF 5; FORCE RESPONSE TO EACH CELL; PROMPT ONCE]

	ALL_4A. How old is this person? (in years)	ALL_4B. Is this person…?	ALL_4C. Smoked at least 100 cigarettes?
Adult 1		O Male O Female	O Yes O No
Adult 2		O Male O Female	O Yes O No
Adult 3		O Male O Female	O Yes O No
Adult 4		O Male O Female	O Yes O No
Adult 5		O Male O Female	O Yes O No

ALL_S5. For each person who smoked 100 or more cigarettes in his or her lifetime, does he or she now smoke every day, some days, or not at all?

Every day 1

Some days 2

Not at all 3

[DISPLAY FOR INELIGIBLE HOUSEHOLDS; TERMINATE AFTER SHOWING]

ABS_END.

Thank you for your participation today.  Your answers to this short survey were very valuable to us, as of this time, all the longer surveys you could participate in have been completed for us so you have not been selected for our study. 

Thanks again for your contribution to this important research.

[DISPLAY IF ADULT1 IS SELECTED (PRIMARY INFORMANT) AND HOUSEHOLD IS SELECTED PER ELIGIBILITY DECISION POINT]

ABS_S6. Good news! You have been selected for our study, which takes about 30 minutes to complete for a $20 or higher reward, depending on your qualification status.

INTRODUCTION.

According to your previous responses, you qualify to participate in a survey that will take about 30 minutes to complete. You will be asked various questions about your experiences with tobacco and television ads about smoking as well as a few questions about your background. The goal of this survey, which will include approximately 10,000 individuals nationwide, is to provide more in-depth analysis of mass media efforts and smoker’s reactions to television ads.

Your responses will be maintained in a secure manner and no personal identification information will be passed on to the sponsors of this study. In addition, your name or other personal information will never be associated with your responses. The data collected for this research study will be combined with that of all participants before it is analyzed.

If you choose to participate in this survey, you will be contacted to participate in a series of follow-up surveys on a quarterly basis. The first follow-up survey will occur in approximately [FILL # MONTHS PLANNED CAMPAIGN DURATION] months. The additional surveys will take about the same amount of time to complete.

There are no physical risks involved in participating in this study; however, it is possible that you could find some of the questions to be sensitive. If you find a question during the survey to be too personal, you may choose not to answer the question. Your participation is strictly voluntary and you may terminate your participation at any time. The benefit of participating in this study is to assist the sponsor in determining a nationwide estimate of awareness of an important media campaign. If you are qualified, [IF KP SAMPLE: you will be awarded 15,000 bonus points credited to your KnowledgePanel account for completing the survey.] [IF ABS SAMPLE: you will receive a check for $20 or more for completing the survey, depending on your qualification status.]

This survey is being conducted on behalf of the Centers for Disease Control and Prevention (www.cdc.gov) and RTI International (www.rti.org), a non-profit research organization that conducts studies on many types of health and social issues. [IF KP SAMPLE: If you have any questions about this study, you can contact KnowledgePanel Panel Relations at 1-800-782-6899 and you will be directed to the appropriate researchers.] If you have any questions about your rights as a study participant, you can contact RTI’s Human Research Protections Office by email at orpe@rti.org, or by phone at 1-866-214-2043 (a toll-free number). Please print or save a copy of this document for your records.

ALL_CONSENT. I have read and understand the information provided above and the study purpose and procedures are clear to me.

Yes, I agree to participate in this study. 1

No, I do not wish to participate in this study. 2

Terminate if ALL_CONSENT ="No" or refused after prompt.

[If R is a current smoker, go to Smoker survey]

[If R is a former smoker or non-smoker, go to Nonsmoker survey]