CHMC-Testing Educational Campaign Materials with African American and Hispanic Audiences

CDC and ATSDR Health Message Testing System

Attachment 3

CHMC-Testing Educational Campaign Materials with African American and Hispanic Audiences

OMB: 0920-0572

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0572 can be found here:

Document [pdf]

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Community Health Media Center – Testing Educational Campaign Materials with African
American and Hispanic Audiences

Attachment 3 – Materials for Hispanic Audiences (English‐speaking)
Contents
Attachment 3a: CHMC Ads for Hispanic Audiences (English‐speaking)…………….………………………….………..……….……………..1
Attachment 3b: Online Eligibility Screener for Hispanic Audiences (English‐speaking)…………………………………………………12
Attachment 3c: Screen Captures of Online Eligibility Screener for Hispanic Audiences (English‐speaking)…………………..19
Attachment 3d: Online Survey for Healthy Drinks for Hispanic Audiences (English‐speaking)…………….……………………….46
Attachment 3e: Screen Captures of Online Survey for Healthy Drinks for Hispanic Audiences (English‐speaking)……….63
Attachment 3f: Online Survey for Physical Activity for Hispanic Audiences (English‐speaking)…………………………………..115
Attachment 3g: Screen Captures of Online Survey for Physical Activity for Hispanic Audiences (English‐speaking)……130
Attachment 3h: Online Survey for Healthy Food for Hispanic Audiences (English‐speaking)…………….…………………..……182
Attachment 3i: Screen Captures of Online Survey for Healthy Food for Hispanic Audiences (English‐speaking).………..198
Attachment 3j: Online Survey for Healthy Living for Hispanic Audiences (English‐speaking)…………………………….…..……250
Attachment 3k: Screen Captures of Online Survey for Healthy Living for Hispanic Audiences (English‐speaking)……….271

Campaign
Shaded

Community

State

Ad Title

Medium

Link

Language

Image/Script

Target
Audience:
Target
African
Audience:
American (from Hispanic (from
CHMC)
CHMC)

Community Health Media Center – Testing Educational Campaign Materials with African American and Hispanic Audiences
Attachment 3a: CHMC Ads for Hispanic Audiences (English‐speaking)
Healthy Drinks: 14
Print: 6, TV: 7, Radio: 1
VO: YOU DO SO MANY THINGS TO
PROTECT YOUR KIDS.

HE‐3

Boston Public
Health
Commission MA

Protection
Radio

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
English
Radio 30 Sec talogID=2048

HE‐4

Boston Public
Health
Commission MA

Protection
Television

HE‐5

Boston Public
Health
Commission MA

Protection‐
Babygate‐
Unhealthy Drink Print

TV 30 Sec

VO: BUT YOU MAY NEVER HAVE
REALIZED ONE OF THE THINGS THAT
CAN HURT THEM.
Yes

Yes

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2055
English

Yes

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2054
English

Yes

Campaign
Shaded

Community

State

Ad Title

Medium

Link

Language

Image/Script

Target
Audience:
Target
African
Audience:
American (from Hispanic (from
CHMC)
CHMC)

HE‐6

Los Angeles
County
Department of
Public Health CA

Choose Health
LA: Unhealthy
Drink
TV 30 Sec

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2196
English

Yes

HE‐7

Los Angeles
County
Department of
Public Health CA

Choose Health
LA: Unhealthy
Drink
Print

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2200
English

Yes

HE‐16

Santa Clara
County Public
Health
Department CA

ReThinkYourDri
nk: Drowning
English
Print

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2427
English

Yes

HE‐17

Tri‐County
Health
Department

Cut Back on
Unhealthy
Drinks:Televisio
n Eng
TV 30 Sec

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2249
English

Yes

Campaign
Shaded

Community

State

Ad Title

HE‐1

New York City
Department of
Health and
Mental
Hygiene
NY

HE‐8

New York City
Department of
Health and
Mental
Hygiene
NY

HE‐10

New York City
Department of
Health and
Mental
Hygiene
NY

Man Walking

HE‐12

New York City
Department of
Health and
Mental
Hygiene
NY

Drinking
Yourself Sick:
Sip In The Right
Direction

Medium

Link

Language

Image/Script

Target
Audience:
Target
African
Audience:
American (from Hispanic (from
CHMC)
CHMC)

Drinking
Yourself Sick:
Adult
Male_Diabetes Print

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2558
English

General
audiences and
adults

Day :30 English TV 30 Sec

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2097
English

Yes

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2089
English

Yes

General
audiences and
adults

TV 45 Sec

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2564

English

Campaign
Shaded

Community

State

Ad Title

Medium

Link

Language

Image/Script

Target
Audience:
Target
African
Audience:
American (from Hispanic (from
CHMC)
CHMC)

HE‐13

New York City
Department of
Health and
Mental
Hygiene
NY

Pouring on the
Pounds: Are You
Drinking
Calories?
English :30
TV 30 Sec

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2420
English

Yes

HE‐14

San Antonio
Metropolitan
Health
District
TX

Find Your
Balance ‐ Dose
of Reality:
Diabetes ‐
Television
TV 30 Sec

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2259
English

Yes

HE‐15

San Antonio
Metropolitan
Health
District
TX

Find Your
Balance‐
Drinking
Fountain‐
Healthy Drink

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2247
English

Yes

Physical Activity: 10
Print: 7, TV: 1, Radio: 2

HE‐30

Miami‐Dade
County Health
Department FL

Make Healthy
Happen Miami:
Imagine What
We Can
Do_Bikes
Print

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2322
English

Campaign
Shaded

Community

State

Ad Title

Medium

Link

Language

Image/Script

Target
Audience:
Target
African
Audience:
American (from Hispanic (from
CHMC)
CHMC)

HE‐31

Miami‐Dade
County Health
Department FL

Make Healthy
Happen Miami:
Safe Walkways
and Bike Paths Print

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2326
English

Yes

HE‐37

Miami‐Dade
County Health
Department FL

Make Healthy
Happen Miami:
Active
Transportation TV 30 Sec

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2347
English

Yes

HE‐26

Centers for
Disease
Control and
Prevention
(CDC)

CDC National
Prevention
Media Initiative:
Playing
Basketball
Print

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2177
English

Yes

HE‐29

N/A

City of
Chicago/Childr
en's Memorial
Hospital
IL

Chicago
Deserves‐
http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
Healthy Places‐
English
Safer Streets
Radio 30 Sec talogID=2207

Safer Streets (30‐second PSA)
(Music plays throughout)
Narrator: Chicagoans deserve to
live, work, learn and play in healthy
environments. We deserve
healthier, people friendly streets for
safe walking and biking. So the City

HE‐32

Campaign
Shaded

Community

State

Pima County
Health
Department AZ

Ad Title

Medium

My Healthy‐
Physical Activity‐
Solutions that
Move
Print

Link

Language

Image/Script

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2139
English

Target
Audience:
Target
African
Audience:
American (from Hispanic (from
CHMC)
CHMC)

Yes

MALE: I TOLD MY SON MARCUS TO
PREPARE FOR AN OPPONENT LIKE
HES NEVER SEEN
AND HE SAID WHO?

HE‐33

Pima County
Health
Department AZ

My Healthy‐
http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
Small Changes‐
English
Basketball
Radio 30 Sec talogID=2149

HE‐27

Centers for
Disease
Control and
Prevention
(CDC)

N/A

Our Community
Deserves: Jungle
Gym Boys
Print

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2464
English

Yes

HE‐28

Centers for
Disease
Control and
Prevention
(CDC)

N/A

Our Community
Deserves: Safer
Streets
Print

http://nccd.cdc.gov/chmc/
Apps/searchdetails.aspx?Ca
talogID=2467#text
English

Yes

TO WHICH I ANSWEREDME.

HE‐34

Campaign
Shaded

Community

State

San Antonio
Metropolitan
Health District TX

Ad Title

Medium

Find Your
Balance ‐
Walking ‐
Physical Activity Print

Link

Language

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2245
English

Image/Script

Target
Audience:
Target
African
Audience:
American (from Hispanic (from
CHMC)
CHMC)

Yes

Healthy Food: 7
Print: 5, TV: 1, Radio 1

HE‐21

Miami‐Dade
County Health
Department FL

Make Healthy
Happen Miami:
Healthy Vending
Machines
Print

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2324
English

Yes

HE‐22

Miami‐Dade
County Health
Department FL

Make Healthy
Happen Miami:
Healthy Vending
Options
TV 30 Sec

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2364
English

Yes

HE‐18

Centers for
Disease
Control and
Prevention
(CDC)

Our Community
Deserves:
Family at
Market
Print

http://nccd.cdc.gov/chmc/
Apps/searchdetails.aspx?Ca
talogID=2465
English

Yes

N/A

Campaign
Shaded

Community

State

Ad Title

Medium

Link

Language

HE‐19

City of
Chicago/Childr
en's Memorial
Hospital
IL

Chicago
Deserves‐
http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
Healthy Places‐
English
Food Options
Radio 30 Sec talogID=2206

HE‐23

Pima County
Health
Department AZ

My Healthy‐
Healthy Choices‐
Community
Nutrition
Print

HE‐24

Pima County
Health
Department AZ

HE‐25

San Antonio
Metropolitan
Health District TX

Image/Script
Food Options (30‐second PSA)
(Music plays throughout)
Narrator: Chicagoans deserve to
live, work, learn and play in healthy
environments. We deserve better
food options that consist of fresh
fruits and vegetables, and lots of

Target
Audience:
Target
African
Audience:
American (from Hispanic (from
CHMC)
CHMC)

Yes

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2135
English

Yes

My Healthy‐
Small Changes‐
Outdoor
Cooking
Print

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2131
English

Yes

Find Your
Balance‐Viva
Veggies‐
Nutrition

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2266
English

Yes

Campaign
Shaded

Community

State

Ad Title

Medium

Link

Language

Image/Script

Target
Audience:
Target
African
Audience:
American (from Hispanic (from
CHMC)
CHMC)

Healthy Living: 10
Print: 5, TV: 3, Radio: 2
TEEN: OBESITY IS AN EPIDEMIC
THAT THREATENS ALL OF US.

HE‐38

Pima County
Health
Department AZ

My Healthy‐
http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
Healthy Choices‐
English
Food Desert
Radio 30 Sec talogID=2150

HE‐39

Pima County
Health
Department AZ

My Healthy‐
Healthy Food‐
Grapes
Basketball

UNHEALTHY FOOD IS
EVERYWHEREON EVERY CORNER.
A NEIGHBORHOOD

Yes

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2128
English

Yes

HE‐40

Pima County
Health
Department AZ

My Healthy‐
Physical Activity‐
Soccer
Print

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2133
English

Yes

HE‐41

Pima County
Health
Department AZ

My Healthy‐
Small Changes‐
Walking
Print

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2132
English

Yes

Campaign
Shaded

Community

State

Ad Title

Medium

Link

Language

HE‐42

Pima County
Health
Department AZ

This Is My
Healthy‐ Active
Living Lifestyle:
Television
TV 30 Sec

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2214
English

HE‐35

Miami‐Dade
County Health
Department FL

Make Healthy
Happen Miami:
Parks
TV 30 Sec

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2363
English

HE‐36

Centers for
Disease
Control and
Prevention
(CDC)

HE‐43

Public Health ‐
Seattle & King
County
WA

N/A

Our Community
http://apps.nccd.cdc.gov/c
hmc/Apps/searchdetails.as
Deserves:
English
Michelle
Radio 30 Sec px?CatalogID=2482

Let's Do This
King County
Television

TV 30s

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2349
English

Image/Script

Narrator: Michelle always wanted to
be a mother. And when that day
came, she did everything she could
to protect her son.
Michelle: No trading lunches at
school today A.J.
Narrator: She volunteered as a room

Target
Audience:
Target
African
Audience:
American (from Hispanic (from
CHMC)
CHMC)

Yes

Campaign
Shaded

Community

State

Ad Title

Medium

Link

Language

Image/Script

Target
Audience:
Target
African
Audience:
American (from Hispanic (from
CHMC)
CHMC)

HE‐44

San Antonio
Metropolitan
Health
District
TX

Find Your
Balance‐More
Sweet Moments‐
Nutrition
Print

http://nccd.cdc.gov/CHMC/
Apps/searchdetails.aspx?Ca
talogID=2272
English

Yes

HE‐45

Los Angeles
County
Department of
Public Health CA

Choose Health
LA: Choose Less‐
Weigh Less:
Cheeseburger Print

http://nccd.cdc.gov/chmc/
Apps/searchdetails.aspx?Ca
talogID=2500
English

Yes

Form Approved
OMB No. 0920-0572
Expiration Date: 2/28/2015

Attachment 3b: Online Eligibility Screener
for Hispanic Audiences (English-speaking)
Community Health Media Center – Testing Educational Campaign
Materials with African American and Hispanic Audiences

SA.

Thank you for taking the time to
complete this survey. Please
indicate below if you would prefer to
take the survey in English or in
Spanish.
1
2

Gracias por tomarse el tiempo de participar en
esta encuesta. Indique a continuación si prefiere
completar la encuesta en inglés o en español.

English (Inglés)
Spanish (Español)

IF RESPONSE 2, SEND RESPONDENT TO HISPANIC-SPANISH SURVEY SCREENER. IF
RESPONSE 1, CONTINUE TO SB IN ENGLISH]
Public Reporting Burden Statement
Public reporting burden of this collection of information is estimated to be approximately 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 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
Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA
(0920-0572).
Notificación al participante sobre el estimado de carga
Se estima que el tiempo de reporte público para esta recopilación de información es un promedio de 3
minutos por respuesta, incluyendo el tiempo para revisar las instrucciones, investigar las fuentes de datos
existentes, recopilar y mantener los datos necesarios, completar y revisar la recopilación de información.
Una agencia no puede realizar ni patrocinar, y no se requiere de ninguna persona que responda a ninguna
recopilación de información, a menos que muestre un número de control actualmente válido de la Oficina
de Administración y Presupuesto (OMB por sus siglas en inglés). Envíe los comentarios sobre el estimado
de esta carga o sobre cualquier otro aspecto de esta recopilación de información, incluyendo sugerencias
para reducir este tiempo, a: CDC/ATSDR, Information Collection Review Office, 1600 Clifton Road NE, MS
D-74, Atlanta, GA 30333, ATTN: PRA (0920-0572).

SB.

Which language are you most comfortable speaking with your friends and family?
1
2
3
4
5
6
7

SC.

English always
English mostly
A little more in English
About the same amount in English and Spanish
A little more in Spanish
Spanish mostly
Spanish always
In what language do you prefer to watch, read, and listen to media (such as TV or radio)?

1
2
3
4
5
6
7

English always
English mostly
A little more in English
About the same amount in English and Spanish
A little more in Spanish
Spanish mostly
Spanish always
IF RESPONSES 4-7 IN SC (CONSUMING MEDIA IN SPANISH), ASK SD. OTHERS SKIP
TO ENGLISH SCREENER INTRODUCTION.

SD.

You mentioned that you watch, read, or listen to media (such as TV or radio) in Spanish, at
least sometimes. We are looking for respondents who are comfortable taking this survey in
Spanish. Are you willing to take the survey in Spanish?
1
2

Yes, I’ll take it in Spanish
No thank you, I prefer to take it in English
IF RESPONSE 1, SEND RESPONDENT TO HISPANIC-SPANISH SCREENER (STARTING
AT INTRODUCTION). IF RESPONSE 2, CONTINUE TO ENGLISH SCREENER
INTRODUCTION.

Introduction
SHOW: About this screener: Thank you for your interest in participating in this survey about health
information. Your participation in this survey is completely voluntary. The screener will take approximately
3 minutes to complete. If you qualify to participate, the online survey will take approximately 22 minutes of
your time. In this online survey, you are going to be shown sample advertisements and asked to share your
honest opinions about them.
Your responses will be entered into a database and will only be seen by researchers associated with this
online survey. Your answers will be kept secure to the extent permitted by law. There will be no risk to you.

You may stop at any time. You will receive your gift, as it is explained in your online survey invitation, after
completing the online survey.
If you have any questions about this online survey or about your rights as an online survey participant,
please email them to StudyInfo@fhi360.org.
By clicking 'Continue,' I am agreeing to the above project description.
GENERAL SCREEN OUT MESSAGE UNLESS OTHERWISE NOTED: Thank you for answering these
questions. Unfortunately, your responses indicate that you did not qualify for this particular online survey,
or that we have already reached our required quota of responses from participants similar to you. We
appreciate your enthusiasm for our online survey and hope you will join us on future online surveys!

Screening Criteria
S1.

What is your gender?
1
2

S2.

Male …………………………………………………………………………………..
Female…………….…………………………………………………………………..
[Recruit Approximately 50% Male and 50% Female]

Continue
Continue

In what year were you born?
1
2
3

S3.

Record year of birth: [4-DIGIT NUMERIC RESPONSE]…………………….
Continue
[Terminate if not age 25 to 64]
Don’t know/Not sure…………………………………….…………………….….
Terminate
Prefer not to answer…………………….………………………………..…….. Terminate
What is the highest level of education you have completed?

1
2
3
4
5
6
7
8

Grade school…………………………………………………………………………..
Less than high school graduate/some high school……………………..………..
High school graduate or completed GED ………………………………………...
Some college or technical school ………………………………………………….
Received four-year college degree…………………………………………………
Some post graduate studies…………………………………………………………
Received advanced degree……………………………………………………….…
Other: _____________________ …………………………………………………

Continue
Continue
Continue
Continue
Continue
Continue
Continue
Continue

S4.

Please indicate your race or ethnic background. Are you….?
SELECT ONE
Ethnicity
1
2

Hispanic or Latino……………………………………………………….…………….
Not Hispanic or Latino……………………………………………………….………..

Continue
Continue

SELECT ONE OR MORE
1
2
3
4
5

Race:
White_............. ………………………………..……….……………………………..
Black or African American………………………………….…………………………
American Indian or Alaska Native…………………………….……………………..
Native Hawaiian or Other Pacific Islander………………………………………..…
Asian…………………………………….…………………………………………….…

Continue
Continue
Continue
Continue
Continue

IF NOT RESPONSE 1 IN ETHNICITY (HISPANIC OR LATINO), SCREEN OUT.
S4-A. You mentioned that you are Hispanic or Latino. What country or countries are you and your
family originally from, before coming to the United States? You may choose as many as
apply. MULTIPLE RESPONSES ALLOWED, DO NOT ROTATE.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21

Argentina
Bolivia
Chile
Colombia
Costa Rica
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Honduras
Mexico
Nicaragua
Panama
Paraguay
Peru
Puerto Rico
Spain
Uruguay
Venezuela
Other (Specify:_______________________________)

S5.

In what state, city, and zip code do you currently live?
1
2
3

State: DROPDOWN LIST OF STATE CODES, ALPHABETIC CODED 1-50….
City: OPEN ENDED……………………………………………………………………
Zip code: NUMERIC FIELD WITH FIVE DIGIT ZIP ENTRY. …………………

Continue
Continue
Continue

S6. Do you, or does any member of your household or immediate family work:
1
2
3
4
5

For a market research company ………………………………………………….
For an advertising agency or public relations firm …………………………………
For the media (TV/radio/newspapers/magazines) ………………………………..
As a healthcare professional (doctor, nurse, pharmacist, dietician, etc.) ……..
None of the above………………………………………………………………….

Terminate
Terminate
Continue
Continue
Continue

S6_1. As a part of your job, are you physically active for a total of at least 30 minutes per work day?
(Add up all the time you spend in any kind of physical activity that increases your heart rate and
makes you breathe hard.)
1
2

Yes……………………………………………………………………………………...
No……………………………………………………………………………………...

Continue
Continue

THERE IS NO S7.
S8.

About how often do you use the Internet?
1
2
3
4
5
6
7
8

S9.

Several times a day…………………………………………………………………
About once a day……………………………………………………………………
3-5 days a week…………………………………………………………………….
1-2 days a week…………………………………………………………………….
Every few weeks…………………………………………………………………….
Less often …………………………………………………………………………..
Never…………………………………………………………………………………
Don’t know…………………………………………………………………………...

Continue
Continue
Continue
Continue
Continue
Continue
Terminate
Continue

About how much do you weigh without shoes?

_____ pounds (or ______ kilos) ………………… ………………………………………
8 Don‘t know / Not sure………………………………………………………………….
9 Prefer not to answer
…………………………………………………………….

Continue
Terminate
Terminate

S10.
1
2

We would like to know approximately how tall you are, without shoes. Are you more comfortable
answering in feet/inches or in meters/centimeters?
Feet/inches ……………………………………………………………………………
Meters/centimeters……………………………………………………………………

Continue
Continue

S10-A. About how tall are you without shoes?
_____ feet and _____ inches (or ______ meter[s] and ______ centimeters)…….…
8 Don‘t know / Not sure………………………………………………………………….
9 Prefer not to answer
……………………………………….…………………….

Continue
Terminate
Terminate

S10_1. CODING, DO NOT DISPLAY – CALCULATE BMI BASED ON S9/S10
CALCULATING BMI (FROM CDC WEBSITE)
FORMULA: [WEIGHT (LB) / [HEIGHT (IN)]2 X 703
Calculate BMI by dividing weight in pounds (lbs) by height in inches (in) squared and multiplying by
a conversion factor of 703.
Example: Weight = 150 lbs, Height = 5'5" (65")
Calculation: [150 ÷ (65)2] x 703 = 24.96
IF BMI IS LESS THAN 18.5, CODE S10_1 AS 1 (UNDERWEIGHT). IF BMI IS AT LEAST 18.5
BUT LESS THAN 25, CODE 10_1 AS 2 (NORMAL). IF BMI IS AT LEAST 25 BUT LESS THAN 30,
CODE 10_1 AS 3 (OVERWEIGHT). IF BMI IS 30 OR ABOVE, CODE 10_1 AS 4 (OBESE).
1
2
3
4
S11.

1
2

UNDERWEIGHT
NORMAL
OVERWEIGHT
OBESE

During the past 7 days, did you drink any regular soft drinks (non-diet) or other sugary drinks – for
example, regular pop or soda (non-diet), sugary sports drinks and energy drinks, and fruit flavored
drinks (not counting 100% fruit juice)?
Yes ……………………………………………...………………………………………… Continue
No……………………………………………...………………………………………… Continue
[IF S11 = 2 (NO), SKIP TO S12. OTHERS CONTINUE TO S11_1]

S11_1. During the past 7 days, on how many days would you say you drank any regular soft drinks (nondiet) or other sugary drinks?
1

Enter number of days: [Numeric Response: 1-7] …………………………………... Continue

S11_2. On [IF S11_1=1, INSERT “that day” IF S11_1>1, INSERT “those ___[INSERT S11_1
RESPONSE]_ days”] when you drank at least one regular soft drink (non-diet) or other sugary
drink, about how many did you drink [IF S11_1>1, INSERT “ on average”]?
1
S12.
1
2

Enter number of drinks: [Numeric Response: 1-100]……..………………………… Continue
During the past 7 days, did you spend time doing any kind of physical activity that increased your
heart rate and made you breathe hard some of the time?
Yes ……………………………………………...………………………………………… Continue
No……………………………………………...………………………………………… Continue
[IF S12 = 2 (NO), SKIP TO S13. OTHERS CONTINUE TO S12_1]

S12_1. During the past 7 days, on how many days would you say you spent time doing any kind of
physical activity that increased your heart rate and made you breathe hard some of the time?
NUMERIC RESPONSE 1-7.
1

Enter number of days: [Numeric Response: 1-7] …………………………………... Continue

S12_2. On [IF S12_1=1, INSERT “that day” IF S12_1>1, INSERT “those ___[INSERT S12_1
RESPONSE]_ days”] when you spent time doing any kind of physical activity that increased your
heart rate and made you breathe hard some of the time, about how many minutes were you
physically active [IF S12_1>1, INSERT “on average”]?
1
S13.
1
2

Enter number of minutes: [Numeric Response: 0-1000]……………………………. Continue
On average, about how many meals and snacks do you eat in a typical day?
_____ number of meals [Numeric Response: 0-10]……………………………….… Continue
_____ number of snacks [Numeric Response: 0-10]…………………………………Continue

S13_1. During the past 7 days, on how many days would you say you ate healthy meals or snacks?
NUMERIC RESPONSE 0-7.
1

Enter number of days: [Numeric Response: 0-7] ………………………………….... Continue
[IF S13_1 = 0, SKIP TO INSTRUCTIONS BEFORE Q1. OTHERS CONTINUE TO S13_2]

S13_2. On [IF S13_1=1, INSERT “that day” IF S13_1>1, INSERT “those ___[INSERT S13_1
RESPONSE]_ days”] when you ate healthy meals or snacks, about how many healthy meals
and snacks did you eat [IF S13_1>1, INSERT “ on average”]?
1
2

_____ number of meals [Numeric Response: 1-10]………………………………… Continue
_____ number of snacks [Numeric Response: 1-10]…………………………………Continue

Attachment 3c: Online Eligibility Screener for Hispanic Audiences (English-Speaking)
Community Health Media Center – Testing Educational Campaign
Materials with African American and Hispanic Audiences

Screenshot – Online Screener Question SA

Screenshot – Online Screener Question SB

Screenshot – Online Screener Question SC

{Note to reviewers: Respondents who indicate “English always,” “English mostly,” or “A little more
in English” will continue to the English screener introduction. Respondents who indicate “About the
same amount in English and Spanish,” “A little more in Spanish,” “Spanish mostly,” or “Spanish
always” in question SC will continue to question SD.}

Screenshot – Online Screener Question SD

{Note to reviewers: Respondents who indicate “Yes, I’ll take it in Spanish” will be sent to the
Hispanic-Spanish screener (starting at the introduction). Respondents who indicate “No thank you, I
prefer to take it in English” continue to the English screener introduction.}

Screenshot – English Screener Introduction

{Note to reviewers: Respondents who wish to participate and click “Continue” will be shown the
following screens.}

Screenshot – Online Screener Question S1

Screenshot – Online Screener Question S2

{Note to reviewers: Respondents who prefer not to answer or who respond “Don’t know/Not sure” to the
question “In what year were you born?,” or who indicate they are not between the ages of 25 and 64, will
be shown the general screen out message below and terminated.* All others will continue to the
questions that follow.}
Screenshot – General Screen Out Message

* This general screen out message will be the same that is shown at any point in the survey in which a respondent’s response does not
meet the screening criteria and they are being terminated.

Screenshot – Online Screener Question S3

Screenshot – Online Screener Question S4

Screenshot – Online Screener Question S4-A

Screenshot – Online Screener Question S5

Screenshot – Online Screener Question S6

{Note to reviewers: Respondents who indicated in question S6 that they or someone in their
household or immediate family works “for a market research company” or “for an advertising
agency or public relations firm” will be shown the general screen out message and terminated. All
others will continue to the questions that follow.}

Screenshot – Online Screener Question S6_1

{Note to reviewers: There is no question S7.}

Screenshot – Online Screener Question S8

{Note to reviewers: Respondents who indicated in question S8 that they “never” use the Internet,
will be shown the general screen out message and terminated. All others will continue to the
questions that follow.}

Screenshot – Online Screener Question S9

{Note to reviewers: Respondents who prefer not to answer, or who respond “Don’t know/Not
sure” to the question “About how much do you weigh without shoes?,” will be shown the general
screen out message and terminated. All others will continue to the question that follow.}

Screenshot – Online Screener Question S10

{Note to reviewers: Respondents who prefer not to answer, or who respond “Don’t know/Not
sure,” to this question will be shown the general screen out message and terminated. All others will
continue to the questions that follow.}

Screenshot – Online Screener Question S10-A

Screenshot – Online Screener Question S11

{Note to reviewers: Respondents who indicated “yes” on question S11 will be shown the following
screen (S11_1). Others will skip to Q12.}

Screenshot – Online Screener Question S11_1

Screenshot – Online Screener Question S11_2

Screenshot – Online Screener Question S12

{Note to reviewers: Respondents who indicated “yes” on question S12 will be shown the following
screen (S12_1). Others will skip to Q13.}

Screenshot – Online Screener Question S12_1

Screenshot – Online Screener Question S12_2

Screenshot – Online Screener Question S13

Screenshot – Online Screener Question S13_1

{Note to reviewers: Only respondents who indicate a number above “0” on S13_1 will be shown
the question below (S13_2), the last question of the screener.}

Screenshot – Online Screener Question S13_2

Form Approved
OMB No. 0920-0572
Expiration Date: 2/28/2015

Attachment 3d: Online Survey for Healthy Drinks
for Hispanic Audiences (English-speaking)
Community Health Media Center – Testing Educational Campaign
Materials with African American and Hispanic Audiences
Introduction
SHOW: About this online survey: Thank you for answering these questions. You are qualified to
participate in this online survey, which is being conducted on behalf of the Centers for Disease
Control and Prevention, sometimes referred to as CDC, in Atlanta. The online survey will take
about 22 minutes to complete. In this online survey, you are going to be shown sample
advertisements and asked to share your honest opinions about them.
Your responses will be entered into a database and will only be seen by researchers associated
with this online survey. Your answers will be kept secure to the extent permitted by law. There will
be no risk to you. You may stop at any time. You will receive your gift, as it is explained in your
online survey invitation, after completing the online survey.
If you have any questions about this online survey or about your rights as an online survey
participant, please email them to StudyInfo@fhi360.org.
By clicking 'Next,' I am agreeing to the above project description.
Public Reporting Burden Statement
Public reporting burden of this collection of information is estimated to average 22 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 Information Collection Review Office, 1600 Clifton Road NE,
MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0572).

[BACKGROUND HEALTH BEHAVIORS AND ATTITUDES]
[Contemplation and Behavioral Intentions]
Pre-Post Questions
[CHECK S11. IF S11=1 (YES), ASK Q1. OTHERS SKIP TO Q1_2]
Q1.

Are you planning to stop drinking regular soft drinks (non-diet) or other sugary drinks within
the next 30 days? SINGLE RESPONSE, DO NOT ROTATE
1
2

Yes………………………………………………………….. Continue
No……………………………………………………………. Continue
[IF Q1=1 SKIP TO Q1_2. IF Q1=2 CONTINUE TO Q1_1]

Q1_1. Are you planning to cut back on regular soft drinks (non-diet) or other sugary drinks within
the next 30 days? SINGLE RESPONSE, DO NOT ROTATE
1
2

Yes………………………………………………………….. Continue
No……………………………………………………………. Continue

Q1_2. Are you planning to be more physically active within the next 30 days? SINGLE
RESPONSE, DO NOT ROTATE
1
2

Yes………………………………………………………..…. Continue
No……………………………………………………………. Continue

Q1_3. Are you planning to eat healthier meals and snacks within the next 30 days? SINGLE
RESPONSE, DO NOT ROTATE
1
2
Q2.

Yes……………………………………………………….…. Continue
No………………………………………………………...…. Continue

Are you planning to do something about your weight within the next 30 days? SINGLE
RESPONSE, ROTATE 1-3.
1
2
3
4

Yes, I plan to try to lose weight……………………….….
Yes, I plan to try to gain weight……………………….….
Yes, I plan to try to maintain my current weight…….….
No, I have no plans to do anything about my weight.….

Continue
Continue
Continue
Continue

Q3.

During the past 12 months, did you try to cut back on regular soft drinks (non-diet) or
other sugary drinks? SINGLE RESPONSE, DO NOT ROTATE
1
2

Yes………………………………………………………….. Continue
No………………………………………………………...…. Continue

Q3_1. During the past 12 months, did you try to be more physically active? SINGLE
RESPONSE, DO NOT ROTATE
1
2

Yes………………………………………………………….. Continue
No………………………………………………………...…. Continue

Q3_2. During the past 12 months, did you try to eat healthier meals and snacks? SINGLE
RESPONSE, DO NOT ROTATE
1
2
Q4.

Yes………………………………………………………….. Continue
No……………………………………………………………. Continue

In the past year, have you tried to do any of the following? MULTIPLE RESPONSE, DO
NOT ROTATE.
1
2
3

Lose weight……………………………………………...…. Continue
Gain weight…………………………………………………. Continue
Maintain your current weight……………………………... Continue

Q4_1. Compared to a year ago, do you weigh…? SINGLE RESPONSE, DO NOT ROTATE.
1
2
3

Less……………………………………….….……………..
More…………………………………………………………
About the same…………………………….………………

Continue
Continue
Continue

Q4_2. And compared to a year ago, would you say that you are…? SINGLE RESPONSE, DO
NOT ROTATE.
1
2
3

More healthy……………………………………………….
Less healthy………………………………….…………….
About the same ……………………………..…………….

Continue
Continue
Continue

[CHECK S11. IF S11=1 (YES) ASK Q5. OTHERS SKIP TO Q7]

Q5.

Overall, on a scale from 1 to 5, where 1 is not at all interested and 5 is extremely
interested, how interested are you in…? SINGLE RESPONSE GRID FORMAT,
RANDOMIZE LIST.
[CHECK S11. IF S11=1 (YES), INSERT A. INSERT B AND C FOR ALL PERSONS]
1
2
3
4
5
A
B
C

Not at all interested………………………………………
A little interested.…………………………………………
Somewhat interested……….……………………………
Very interested……………………………………………
Extremely interested ………………………………….…

Continue
Continue
Continue
Continue
Continue

Cutting back on regular soft drinks (non-diet) or other sugary drinks
Being more physically active
Eating healthier meals and snacks

[THERE IS NO Q6.]
Q7.

Thinking about the next six months, how likely are you to…? Please use a scale from 1 to
5, where 1 is not at all likely and 5 is extremely likely. SINGLE RESPONSE GRID
FORMAT, ROTATE LIST.
1
2
3
4
5
A
B
C

Not at all likely…………………………………………..…
Somewhat unlikely..………………………………………
Neither likely nor unlikely..…………………………….…
Somewhat likely..……………………………………….…
Extremely likely …………………………………………...

Continue
Continue
Continue
Continue
Continue

Look for more information on the health benefits of cutting back on regular soft
drinks (non-diet) or other sugary drinks
Talk to a friend about the health benefits of cutting back on regular soft drinks
(non-diet) or other sugary drinks
Participate in community efforts to reduce obesity

[Self-Efficacy Questions]
Q8.

Strongly disagree…………………………………………..
Somewhat disagree…………………………………….....
Neither agree nor disagree……………………………….
Somewhat agree…………………………………………..
Strongly agree……………………………………………..

Continue
Continue
Continue
Continue
Continue

Strongly disagree……………………………………….….
Somewhat disagree………………………………………..
Neither agree nor disagree…………………………….….
Somewhat agree……………………………………………
Strongly agree………………………………………………

Continue
Continue
Continue
Continue
Continue

[Community Attitudes]
Q10.
1
2
3

Which of the following statements best describes how you think the problem of obesity
should be solved in your community? SINGLE RESPONSE, ROTATE 1-2.
Obesity is an individual problem that is best solved by people taking personal
responsibility for what they eat and how physically active they are………………. Continue
Obesity is a community problem that is best solved by people working together
to make it easier for everyone to eat healthy foods and be physically active……. Continue
Obesity is both an individual and community problem that is best solved by people taking
personal responsibility for what they eat and how physically active they are, and the
community working together to make these behaviors easier to do ….………….. Continue

CAMPAIGN EVALUATIONS
SOME RESPONDENTS WILL FIRST SEE A SET OF ADS THAT CORRESPOND TO A
DISCRETE CAMPAIGN (RANDOMLY CHOSEN). AFTER EACH AD SHOWN, ASK Q12-Q19.
AFTER THE ENTIRE CAMPAIGN IS SHOWN, ASK Q20.
Q11.

CAMPAIGN SHOWN – CODE, DO NOT DISPLAY

SHOW: Now we would like to show you a few different health-related ads, including a television,
print, and/or radio ad, and then ask you to evaluate each ad. Even if an ad is from another
community or city, please rate it as if it were an ad from your local community. Also, please note
that the video quality of these ads may vary – please rate them based on the content of the ads,
not on the quality of the video.
Please make sure the volume on your computer is turned up, so that you may both see and/or hear
the TV and radio ads.
Please click “Next” to continue.
NOTE: WHEN THE TV ADS ARE PRESENTED, PLEASE SHOW THE FOLLOWING MESSAGE
ABOVE THE SCREEN: This ad is a TV ad. Please be patient while the video loads; also note that
the video may stop to buffer from time to time. We do not expect buffering to continue for more
than 30 seconds. If you find that it is buffering too long, you can suspend the survey at any time
and return to this point in the survey simply by clicking on the original survey link.
And remember: even if an ad is from another community or city, please rate it as if it were an ad
from your local community.
NOTE: WHEN THE RADIO ADS ARE PRESENTED, PLEASE SHOW THE FOLLOWING
MESSAGE ABOVE THE SCREEN: This ad is a radio ad. Please be patient while the audio
loads; also note that the audio may stop to buffer from time to time. We do not expect buffering to

continue for more than 30 seconds. If you find that it is buffering too long, you can suspend the
survey at any time and return to this point in the survey simply by clicking on the original survey
link.
And remember: even if an ad is from another community or city, please rate it as if it were an ad
from your local community.
Questions for Each Ad
SHOW: Please answer the following questions about the ad you just viewed.
Q12.

If you saw or heard this message, would it get your attention? SINGLE RESPONSE, DO
NOT ROTATE
1
2

Yes………………………………………………………….. Continue
No……………………………………………………...……. Continue

Q13.

Why or why not? OPEN ENDED…………………………………………….

Q14.

Is this message believable? SINGLE RESPONSE, DO NOT ROTATE
1
2

Continue

Yes………………………………………………………….. Continue
No……………………………………………………...……. Continue

Q15.

Why or why not? OPEN ENDED…………………………………………….

Q16.

Did you think this ad would be effective to motivate you or someone else to cut back on
regular soft drinks or other sugary beverages – for example, regular pop or soda (nondiet), sugary sports drinks and energy drinks, fruit flavored drinks (not counting 100% fruit
juice), or other sugary drinks?
Please use a scale from 1 to 5, where 1 is not at all effective and 5 is extremely effective.
SINGLE RESPONSE, DO NOT ROTATE
1
2
3
4
5

Not at all effective…………………………………………
Somewhat ineffective.………………………………….…
Neither effective nor ineffective……………………….…
Somewhat effective…………………………………….…
Extremely effective ……………………………………….

Continue

Continue
Continue
Continue
Continue
Continue

Q17.

Who would you say this ad is trying to reach? Please check all that apply. MULTIPLE
RESPONSE, DO NOT ROTATE
1
2
3

Q18.

You…………………………………………………………..
People like you……………………………………….…….
Someone else………………………………………..…….

Continue
Continue
Continue

On a scale from 1 to 5, where 1 indicates that you strongly disagree, and 5 indicates that
you strongly agree, please indicate how much you agree or disagree with each of the
following statements about this advertisement. SINGLE RESPONSE GRID FORMAT.
RANDOMIZE LIST.
1
2
3
4
5
A
B
C
D
E
F
G
H
I
J
K

Strongly disagree…………………………………………..
Somewhat disagree………………………………………..
Neither agree nor disagree………………………….…….
Somewhat agree……………………………………………
Strongly agree………………………………………………

Continue
Continue
Continue
Continue
Continue

Overall, I liked this ad
I am interested in this ad’s topic
I trust the information in this ad
This ad was confusing
This ad was convincing
This ad said something important to me
This ad grabbed my attention
I learned something new from this ad
I can do what this ad suggests
This ad was easy to understand
I would notice this ad if I saw/heard it

IF RESPONSE 4 OR 5 TO Q18G, ASK Q19. OTHERS SKIP TO INSTRUCTIONS
BEFORE Q20.
Q19.

You mentioned that this ad grabbed your attention. What makes it stand out? OPEN
ENDED…………………………………………………………………………… Continue

BEFORE THE NEXT AD IS EVALUATED, UNTIL THE LAST AD, SHOW: Now you will see
another ad to evaluate. Once again, even if an ad is from another community or city, please rate it
as if it were an ad from your local community. Please note that we would like your reaction to each
ad individually – we will not ask you to compare one ad to any other.
[ONLY ASK Q20 ONCE A WHOLE “CAMPAIGN” IS EVALUATED]

Campaign Summary Evaluation
Q20.

Considering the impact of these ads together, please indicate how much you agree or
disagree with each statement. SINGLE RESPONSE GRID FORMAT, RANDOMIZE LIST.
1
2
3
4
5
A
B
C
D
E
F
G

Strongly disagree…………………….…………………….
Somewhat disagree………………………………………..
Neither agree nor disagree…………….………………….
Somewhat agree……………………………………………
Strongly agree………………………………………………

Continue
Continue
Continue
Continue
Continue

I trust the information in this set of ads.
This set of ads was convincing.
This set of ads grabbed my attention.
This set of ads told me something I didn’t already know.
The message about regular soft drinks (non-diet) or other sugary drinks in this set
of ads was persuasive.
This set of ads gave me good reasons to cut back on regular soft drinks (non-diet)
or other sugary drinks.
This set of ads gave me good reasons to stop drinking regular soft drinks (nondiet) or other sugary drinks.

BEFORE THE SECOND CAMPAIGN SEQUENCE IS EVALUATED, SHOW: Now you will see
another series of ads to evaluate. Once again, even if an ad is from another community or city,
please rate it as if it were an ad from your local community.

INDIVIDUAL SPOT EVALUATIONS
EACH RESPONDENT WILL SEE A SET OF RANDOMLY CHOSEN INDIVIDUAL ADS. AFTER
EACH AD SHOWN, ASK Q22-Q29.
Q21.

ADS SHOWN – CODE, DO NOT DISPLAY, ADS SHOWN

NOTE: WHEN THE TV ADS ARE PRESENTED, PLEASE SHOW THE FOLLOWING MESSAGE
ABOVE THE SCREEN: This ad is a TV ad. Please be patient while the video loads; also note that
the video may stop to buffer from time to time. We do not expect buffering to continue for more
than 30 seconds. If you find that it is buffering too long, you can suspend the survey at any time
and return to this point in the survey simply by clicking on the original survey link.
And remember: even if an ad is from another community or city, please rate it as if it were an ad
from your local community.
NOTE: WHEN THE RADIO ADS ARE PRESENTED, PLEASE SHOW THE FOLLOWING
MESSAGE ABOVE THE SCREEN: This ad is a radio ad. Please be patient while the audio
loads; also note that the audio may stop to buffer from time to time. We do not expect buffering to
continue for more than 30 seconds. If you find that it is buffering too long, you can suspend the
survey at any time and return to this point in the survey simply by clicking on the original survey
link.
And remember: even if an ad is from another community or city, please rate it as if it were an ad
from your local community.

Questions for Each Ad
SHOW: Please answer the following questions about the ad you just viewed.
Q22.

If you saw or heard this message, would it get your attention? SINGLE RESPONSE, DO
NOT ROTATE
1
2

Yes…………………………………………….……………. Continue
No……………………………………………..…………….. Continue

Q23.

Why or why not? OPEN ENDED…………………………………………….. Continue

Q24.

Is this message believable? SINGLE RESPONSE, DO NOT ROTATE
1
2

Q25.

Yes………………………………………….………………. Continue
No………………………………………….………………... Continue

Why or why not? OPEN ENDED…………………………..………………… Continue

Q26.

Did you think this ad would be effective to motivate you or someone else to cut back on
regular soft drinks or other sugary drinks – for example, regular pop or soda (non-diet),
sugary sports drinks and energy drinks, fruit flavored drinks (not counting 100% fruit juice),
or other sugary drinks?
Please use a scale from 1 to 5, where 1 is not at all effective and 5 is extremely effective.
SINGLE RESPONSE, DO NOT ROTATE
1
2
3
4
5

Q27.

Continue
Continue
Continue
Continue
Continue

Who would you say this ad is trying to reach? Please check all that apply. MULTIPLE
RESPONSE, DO NOT ROTATE.
1
2
3

Q28.

Not at all effective…………………………………….……
Somewhat ineffective.………………………………….…
Neither effective nor ineffective………………………..…
Somewhat effective……………………………………..…
Extremely effective ………………………………………..

You………………………………………………………….. Continue
People like you…………………………………………….. Continue
Someone else……………………………………..……….. Continue

Strongly disagree…………………………………….…….
Somewhat disagree………………………………………..
Neither agree nor disagree………………………….…….
Somewhat agree……………………………………………
Strongly agree………………………………………………

Continue
Continue
Continue
Continue
Continue

IF RESPONSE 4 OR 5 TO Q28G, ASK Q29. OTHERS SKIP TO INSTRUCTIONS AFTER
Q29.

Q29.

You mentioned that this ad grabbed your attention. What makes it stand out? OPEN
ENDED………………………………………………………………………..… Continue

BEFORE THE NEXT AD IS EVALUATED, UNTIL THE LAST AD, SHOW: Now you will see
another ad to evaluate. Once again, even if an ad is from another community or city, please rate it
as if it were an ad from your local community. Please note that we would like your reaction to each
ad individually – we are not interested in comparing any of the ads to one another.
Pre-Post Questions
[Behavioral Intentions]
[CHECK S11. IF S11=1 (YES), ASK Q30. OTHERS SKIP TO Q30_2]
Q30.

Are you planning to stop drinking regular soft drinks (non-diet) or other sugary drinks within
the next 30 days? SINGLE RESPONSE, DO NOT ROTATE.
1
2

Yes……………………………………….………………….. Continue
No……………………………………………………………. Continue
[IF Q30=1 SKIP TO Q30_2. IF Q30=2 CONTINUE TO Q30_1]

Q30_1. Are you planning to cut back on regular soft drinks (non-diet) or other sugary drinks within
the next 30 days? SINGLE RESPONSE, DO NOT ROTATE.
1
2

Yes………………………………………………………….. Continue
No……………………………………………………………. Continue

Q30_2. Are you planning to be more physically active within the next 30 days? SINGLE
RESPONSE, DO NOT ROTATE.
1
2

Yes……………………………………..……………………. Continue
No……………………………………………………………. Continue

Q30_3. Are you planning to eat healthier meals and snacks within the next 30 days? SINGLE
RESPONSE, DO NOT ROTATE.
1
2

Yes……………………………………..……………………. Continue
No……………………………………………………………. Continue

Q31.

Are you planning to do something about your weight within the next 30 days? SINGLE
RESPONSE, ROTATE 1-3.
1
2
3
4

Yes, I plan to try to lose weight……………………..…….
Yes, I plan to try to gain weight……………………..…….
Yes, I plan to try to maintain my current weight……..….
No, I have no plans to do anything about my weight..….

Continue
Continue
Continue
Continue

[CHECK S11. IF S11=1 (YES), ASK Q32. OTHERS SKIP TO Q32_1]
Q32.

Overall, on a scale from 1 to 5, where 1 is not at all interested and 5 is extremely
interested, how interested are you in cutting back on regular soft drinks (non-diet) or other
sugary drinks? SINGLE RESPONSE, DO NOT ROTATE.
1
2
3
4
5

Not at all interested………………………………..………
A little interested.……………………………………..……
Somewhat interested……….…………………………..…
Very interested……………………………………………..
Extremely interested ………………………………………

Continue
Continue
Continue
Continue
Continue

Q32_1. Overall, on a scale from 1 to 5, where 1 is not at all interested and 5 is extremely
interested, how interested are you in trying to be more physically active? SINGLE
RESPONSE, DO NOT ROTATE.
1
2
3
4
5

Not at all interested…………………………………..……
A little interested.………………………………………..…
Somewhat interested……….…………………………..…
Very interested…………………………………………..…
Extremely interested ………………………………………

Continue
Continue
Continue
Continue
Continue

Q32_2. Overall, on a scale from 1 to 5, where 1 is not at all interested and 5 is extremely
interested, how interested are you in trying to eat healthier meals and snacks? SINGLE
RESPONSE, DO NOT ROTATE.
1
2
3
4
5

Continue
Continue
Continue
Continue
Continue

[THERE IS NO Q33]

Q34.

Thinking about the next six months, how likely are you to…? Please use a scale from 1 to
5, where 1 is not at all likely and 5 is extremely likely. SINGLE RESPONSE GRID
FORMAT, RANDOMIZE LIST
1
2
3
4
5
A
B
C

Not at all likely……………………………………...………
Somewhat unlikely..………………………………….……
Neither likely nor unlikely..……………………………..…
Somewhat likely..………………………………………..…
Extremely likely …………………………………………....

Continue
Continue
Continue
Continue
Continue

[Self-Efficacy Questions]
Q35.

Strongly disagree………………………………………….
Somewhat disagree…………………………………...…..
Neither agree nor disagree……………………………….
Somewhat agree……………………………………...……
Strongly agree………………………………………………

Continue
Continue
Continue
Continue
Continue

Q36.

Continue
Continue
Continue
Continue
Continue

Which of the following statements best describes how you think the problem of obesity
should be solved in your community? SINGLE RESPONSE, ROTATE 1-2.
Obesity is an individual problem that is best solved by people taking personal
responsibility for what they eat and how physically active they are………………. Continue
Obesity is a community problem that is best solved by people working together
to make it easier for everyone to eat healthy foods and be physically active….... Continue
Obesity is both an individual and community problem that is best solved by people taking
personal responsibility for what they eat and how physically active they are, and the
community working together to make these behaviors easier to do……………… Continue

CLASSIFICATION
SHOW: You’re almost done! These last few questions are for classification purposes only and will
be used for analyzing the results of the survey in total. They will not be identified with you
personally.
C1.

Has a healthcare professional ever told you that you are overweight or at risk for being
overweight? SINGLE RESPONSE, DO NOT ROTATE
1
2
3

C2.

Yes………………………………………………………….. Continue
No………………………………………………………...…. Continue
Don’t know / not sure …………………………………..…. Continue

What is your current occupational status? Are you…? Please select the option that best
applies to you. SINGLE RESPONSE, DO NOT ROTATE.
1
2
3
4
5
6
7
8
10

C4.

Continue
Continue
Continue

Has anyone else in your household been identified by a health care professional as being
overweight or at risk for being overweight? SINGLE RESPONSE DO NOT ROTATE
1
2
3

C3.

Yes……………………………………………….……...….
No……………………………………………………..…….
Don’t know / not sure ………………………………….….

Employed full time………………………………………...
Employed part time………………………………………..
Unemployed………………………………………………..
Homemaker………………………………………………..
Student ………………………………………………..…...
Retired ………………………………………………..…....
Disabled …………………………………………………...
Other (Please specify: _________)………………..…....
Prefer not to answer……..………………………………...

Continue
Continue
Continue
Continue
Continue
Continue
Continue
Continue
Continue

What is your marital status? SINGLE RESPONSE, ROTATE 1-6.
1
2
3
4
5
6
8

Married ……………………………………………….……
Unmarried living with a partner……………………….…
Divorced ………………………………………………..…
Widowed ………………………………………………..…
Separated……………………………………………….…
Single, never been married ……………………………..
Prefer not to answer……..…………………………….….

Continue
Continue
Continue
Continue
Continue
Continue
Continue

C5.

How many children (under age 18) live in your household?
1
2

C6.

Continue
Continue

What is your household’s total income from all sources before taxes? SINGLE
RESPONSE, DO NOT ROTATE
1
2
3
4
5
6
7
8
9

C7.

Enter number: [Numeric Response] …………….………………
Prefer not to answer [Check Box]……..………………………….

Under $20,000……..………………………………....…………….
$20,000 to $29,999 .…………………………….………………….
$30,000 to $39,999 .…………………………….………………….
$40,000 to $49,999 .…………………………….………………….
$50,000 to $74,999 .…………………………….………………….
$75,000 to $99,999 .…………………………….………………….
$100,000 to $199,999 .…………………………….…………….…
$200,000 or more.……………………..………….………………...
Prefer not to answer.…………………………….………………….

Continue
Continue
Continue
Continue
Continue
Continue
Continue
Continue
Continue

In the following list of items, please indicate which devices you currently use or own.
MULTIPLE RESPONSE, ROTATE LIST.
1
2
3
4
5
6

A desktop computer………………………………………………… Continue
A laptop computer…………………………………………………… Continue
A smartphone, such as an iPhone, BlackBerry, Android, Windows phone, etc.
………………………………………………………….……………… Continue
A tablet, such as an iPad, Kindle Fire, Nook Color, Motorola Xoom, etc.
……………………………………………………………………….… Continue
An iPod or other mp3 player ……………………………………..… Continue
None of these – EXCLUSIVE - ANCHOR

SHOW: Thank you for your time. Please click “OK” to confirm your participation.

Attachment 3e: Screen Captures of Online Survey for Healthy Drinks for Hispanic Audiences (English-speaking)
Community Health Media Center – Testing Educational Campaign
Materials with African American and Hispanic Audiences
Screenshot – Online Survey Start Screen

{Note to reviewers: Only respondents who selected “yes” for screener QS11,“did you drink any regular soft drinks
(non-diet) or other sugary drinks,?” will be shown the following screen (Q1). Others will skip to Q1_2.}
Screenshot – Online Survey Question Q1

{Note to reviewers: Only respondents who selected “no” for Q1,“are you planning to stop drinking regular soft
drinks (non-diet) or other sugary drinks?,” will be shown the following screen (Q1_1). Others will skip to Q1_2.}
Screenshot - Online Survey Question Q1_1

Screenshot – Online Survey Question Q1_2

Screenshot - Online Survey Question Q1_3

Screenshot – Online Survey Question Q2

Screenshot – Online Survey Question Q3

Screenshot – Online Survey Question Q3_1

Screenshot – Online Survey Question Q3_2

Screenshot – Online Survey Question Q4

Screenshot – Online Survey Question 4_1

Screenshot – Online Survey Question Q4_2

{Note to reviewers: All respondents will be asked Q5. However, respondents who had selected “no” for screener
QS11, “did you drink any regular soft drinks (non-diet) or other sugary drinks?,” will not be shown the item in Q5
that asks “how interested are you in cutting back on regular soft drinks (non-diet) or other sugary drinks.”}
Screenshot – Online Survey Question Q5

{Note to reviewers: There is no Q6}
Screenshot – Online Survey Question Q7

Screenshot – Online Survey Question Q8

Screenshot – Online Survey Question Q9

Screenshot – Online Survey Question Q10

{Note to reviewers: At this point, some respondents will be shown a set of ads (TV, radio and/or print) that
correspond to a discrete campaign (randomly chosen). Others will be shown randomly chosen individual ads that
do not correspond to a discrete campaign. After each ad is shown, they will be asked Q12-Q19. }
Screenshot: Initial Screen for Ad Evaluations

{Note to reviewers: The screen below is a sample of the screen respondents will see when viewing each ad. The
questions they will be asked for each ad will be the same, regardless of the ad they see.}
Screenshot: Sample Screen of Ad Presentation

Screenshot: Ad Survey Question Introduction Page

Screenshot – Online Survey Question Q12

Screenshot – Online Survey Question Q13

Screenshot – Online Survey Question Q14

Screenshot – Online Survey Question Q15

Screenshot – Online Survey Question Q16

Screenshot – Online Survey Question Q17

Screenshot – Online Survey Question Q18

{Note to reviewers: Only respondents who selected “somewhat agree” or “strongly agree” on Q18 for the item
“This ad grabbed my attention,” will be shown the question below (Q19). Others will skip to next ad or, if
appropriate, will be shown Q20.}
Screenshot – Online Survey Question Q19

Screenshot: Transition Page before Each Ad

{Note to reviewers: Q20 below will only be shown if respondents have evaluated individual ads that together
comprise a campaign.}
Screenshot – Online Survey Question Q20

{Note to reviewers: At this point, respondents who were being shown individual
ads corresponding to a discrete campaign, will begin seeing a set of randomly
chosen individual ads (TV, radio, and/or print) that do not correspond to a
campaign. Those who were already being shown individual ads not
corresponding to a campaign, will continue to be shown individual spots. After
each ad is shown, they will be asked Q22-29 (which are the same as Q12-Q19,
presented above). Respondents will then see the questions that follow.}

{Note to reviewers: Only respondents who selected “yes” for screener QS11, “did you drink any regular soft drinks
(non-diet) or other sugary drinks?,” will be shown the following screen (Q30). Others will skip to Q30_2.}
Screenshot – Online Survey Question Q30

{Note to reviewers: Only respondents who selected “no” for Q30, “are you planning to stop drinking regular soft
drinks (non-diet) or other sugary drinks?,” will be shown the following screen (Q30_1). Others will skip to Q30_2.}
Screenshot – Online Survey Question Q30_1

Screenshot – Online Survey Question Q30_2

Screenshot – Online Survey Question Q30_3

Screenshot – Online Survey Question Q31

{Note to reviewers: Only respondents who selected “yes” for screener QS11, “did you drink any regular soft drinks
(non-diet) or other sugary drinks?,” will be shown the following screen (Q32). Those who responded “no” to QS11
on the screener will skip to Q32_1.}
Screenshot – Online Survey Question Q32

Screenshot – Online Survey Question Q32_1

100

Screenshot – Online Survey Question Q32_2

101

Screenshot – Online Survey Question Q34

102

Screenshot – Online Survey Question Q35

103

Screenshot – Online Survey Question Q36

104

Screenshot – Online Survey Question Q37

105

Screenshot: Initial Screen for Classification Questions

106

Screenshot – Online Survey Question C1

107

Screenshot – Online Survey Question C2

108

Screenshot – Online Survey Question C3

109

Screenshot – Online Survey Question C4

110

Screenshot – Online Survey Question C5

111

Screenshot – Online Survey Question C6

112

Screenshot – Online Survey Question C7

113

Screenshot – Survey End Page

114

Form Approved
OMB No. 0920-0572
Expiration Date: 2/28/2015

Attachment 3f: Online Survey for Physical Activity
for Hispanic Audiences (English-speaking)
Community Health Media Center – Testing Educational Campaign
Materials with African American and Hispanic Audiences
Introduction
SHOW: About this online survey: Thank you for answering these questions. You are qualified to participate
in this online survey, which is being conducted on behalf of the Centers for Disease Control and
Prevention, sometimes referred to as CDC, in Atlanta. The online survey will take about 22 minutes to
complete. In this online survey, you are going to be shown sample advertisements and asked to share your
honest opinions about them.
Your responses will be entered into a database and will only be seen by researchers associated with this
online survey. Your answers will be kept secure to the extent permitted by law. There will be no risk to you.
You may stop at any time. You will receive your gift, as it is explained in your online survey invitation, after
completing the online survey.
If you have any questions about this online survey or about your rights as an online survey participant,
please email them to StudyInfo@fhi360.org.
By clicking 'Next,' I am agreeing to the above project description.
Public Reporting Burden Statement
Public reporting burden of this collection of information is estimated to average 22 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 Information
Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (09200572).

115

[BACKGROUND HEALTH BEHAVIORS AND ATTITUDES]
[Contemplation and Behavioral Intentions]
Pre-Post Questions
[CHECK S11. IF S11=1 (YES), ASK Q1. OTHERS SKIP TO Q1_2]
Q1.

Are you planning to stop drinking regular soft drinks (non-diet) or other sugary drinks within the
next 30 days? SINGLE RESPONSE, DO NOT ROTATE
1
2

Yes………………………………….……………………….. Continue
No……………………………………………………………. Continue
[IF Q1=1 SKIP TO Q1_2. IF Q1=2 CONTINUE TO Q1_1]

Q1_1. Are you planning to cut back on regular soft drinks (non-diet) or other sugary drinks within the next
30 days? SINGLE RESPONSE, DO NOT ROTATE
1
2

Yes………………………………….……………………….. Continue
No……………………………………………………………. Continue

Q1_2. Are you planning to be more physically active within the next 30 days? SINGLE RESPONSE, DO
NOT ROTATE
1
2

Yes…………………………………………………..………. Continue
No……………………………………………………………. Continue

Q1_3. Are you planning to eat healthier meals and snacks within the next 30 days? SINGLE
RESPONSE, DO NOT ROTATE
1
2
Q2.

Yes…………………………………………………..………. Continue
No……………………………………………………………. Continue

Are you planning to do something about your weight within the next 30 days? SINGLE
RESPONSE, ROTATE 1-3.
1
2
3
4

Yes, I plan to try to lose weight…………………….…….
Yes, I plan to try to gain weight…………………….…….
Yes, I plan to try to maintain my current weight….…….
No, I have no plans to do anything about my weight.….

Continue
Continue
Continue
Continue

116

Q3.

During the past 12 months, did you try to cut back on regular soft drinks (non-diet) or other sugary
drinks? SINGLE RESPONSE, DO NOT ROTATE
1
2

Yes………………………………………………………….. Continue
No……………………………………………………...……. Continue

Q3_1. During the past 12 months, did you try to be more physically active? SINGLE RESPONSE, DO
NOT ROTATE
1
2

Yes………………………………………………………….. Continue
No……………………………………………………………. Continue

Q3_2. During the past 12 months, did you try to eat healthier meals and snacks? SINGLE RESPONSE,
DO NOT ROTATE
1
2
Q4.

Yes………………………………………………………….. Continue
No……………………………………………………...……. Continue

In the past year, have you tried to do any of the following? MULTIPLE RESPONSE, DO NOT
ROTATE.
1
Lose weight…………………………………………………. Continue
2
Gain weight…………………………………………………. Continue
3
Maintain your current weight…………………………….... Continue

Q4_1. Compared to a year ago, do you weigh…? SINGLE RESPONSE, DO NOT ROTATE.
1
2
3

Less……………………………………….………………...
More…………………………………………………………
About the same………………………………………….…

Continue
Continue
Continue

Q4_2. And compared to a year ago, would you say that you are…? SINGLE RESPONSE, DO NOT
ROTATE.
1
2
3

More healthy……………………………………………….. Continue
Less healthy………………………………………………... Continue
About the same ……………………………………………. Continue

117

Q5.

Overall, on a scale from 1 to 5, where 1 is not at all interested and 5 is extremely interested, how
interested are you in…? SINGLE RESPONSE GRID FORMAT, RANDOMIZE LIST.
[CHECK S11. IF S11=1 (YES), INSERT A. INSERT B AND C FOR ALL PERSONS]
1
2
3
4
5
A
B
C

Continue
Continue
Continue
Continue
Continue

Cutting back on regular soft drinks (non-diet) or other sugary drinks
Being more physically active
Eating healthier meals and snacks

[THERE IS NO Q6.]
Q7.

Thinking about the next six months, how likely are you to…? Please use a scale from 1 to 5, where
1 is not at all likely and 5 is extremely likely. SINGLE RESPONSE GRID FORMAT, ROTATE LIST.
1
2
3
4
5
A
B
C

Not at all likely…………………………………………..…
Somewhat unlikely..………………………………………
Neither likely nor unlikely..…………………………….…
Somewhat likely..…………………………………………
Extremely likely …………………………………………..

Continue
Continue
Continue
Continue
Continue

Look for more information on the health benefits of being more physically active
Talk to a friend about the health benefits of being more physically active
Participate in community efforts to reduce obesity

[Self-Efficacy Questions]
Q8.

Strongly disagree…………………………………………..
Somewhat disagree………………………………………..
Neither agree nor disagree………………………………..
Somewhat agree……………………………………………
Strongly agree………………………………………………

Continue
Continue
Continue
Continue
Continue

I feel as though I can make a difference regarding my risk for being overweight or obese
I am confident that I can protect myself from being overweight or obese
There are many things I can do to protect myself from being overweight or obese
Generally speaking, it is possible to reduce one’s risk for being overweight or obese

118

[Behavioral Beliefs]
Q9.

Strongly disagree…………………………………………. Continue
Somewhat disagree………………………………………. Continue
Neither agree nor disagree………………………………. Continue
Somewhat agree………………………………………...… Continue
Strongly agree…………………………………………...… Continue

Which of the following statements best describes how you think the problem of obesity should be
solved in your community? SINGLE RESPONSE, ROTATE 1-2.
Obesity is an individual problem that is best solved by people taking personal
responsibility for what they eat and how physically active they are…………………. Continue
Obesity is a community problem that is best solved by people working together
to make it easier for everyone to eat healthy foods and be physically active………. Continue
Obesity is both an individual and community problem that is best solved by people taking personal
responsibility for what they eat and how physically active they are, and the community working
together to make these behaviors easier to do……………….……………………….. Continue

CAMPAIGN EVALUATIONS
SOME RESPONDENTS WILL FIRST SEE A SET OF ADS THAT CORRESPOND TO A DISCRETE
CAMPAIGN (RANDOMLY CHOSEN). AFTER EACH AD SHOWN, ASK Q12-Q19. AFTER THE ENTIRE
CAMPAIGN IS SHOWN, ASK Q20.
Q11.

CAMPAIGNS SHOWN – CODE, DO NOT DISPLAY

119

SHOW: Now we would like to show you a few different health-related ads, including a television, print,
and/or radio ad, and then ask you to evaluate each ad. Even if an ad is from another community or city,
please rate it as if it were an ad from your local community. Also, please note that the video quality of these
ads may vary – please rate them based on the content of the ads, not on the quality of the video.
Please make sure the volume on your computer is turned up, so that you may both see and/or hear the TV
and radio ads.
Please click “Next” to continue.
NOTE: WHEN THE TV ADS ARE PRESENTED, PLEASE SHOW THE FOLLOWING MESSAGE ABOVE
THE SCREEN: This ad is a TV ad. Please be patient while the video loads; also note that the video may
stop to buffer from time to time. We do not expect buffering to continue for more than 30 seconds. If you
find that it is buffering too long, you can suspend the survey at any time and return to this point in the
survey simply by clicking on the original survey link.
And remember: even if an ad is from another community or city, please rate it as if it were an ad from your
local community.
NOTE: WHEN THE RADIO ADS ARE PRESENTED, PLEASE SHOW THE FOLLOWING MESSAGE
ABOVE THE SCREEN: This ad is a radio ad. Please be patient while the audio loads; also note that the
audio may stop to buffer from time to time. We do not expect buffering to continue for more than 30
seconds. If you find that it is buffering too long, you can suspend the survey at any time and return to this
point in the survey simply by clicking on the original survey link.
And remember: even if an ad is from another community or city, please rate it as if it were an ad from your
local community.
Questions for Each Ad
SHOW: Please answer the following questions about the ad you just viewed.
Q12.

If you saw or heard this message, would it get your attention? SINGLE RESPONSE, DO NOT
ROTATE
1
2

Yes……………………………………………….………….. Continue
No……………………………………………………………. Continue

Q13.

Why or why not? OPEN ENDED…………………………………………….

Q14.

Is this message believable? SINGLE RESPONSE, DO NOT ROTATE
1
2

Q15.

Continue

Yes…………………………………………………………..
No………………………………………………………..….

Continue
Continue

Why or why not? OPEN ENDED…………………………………………….

Continue

120

Q16.

Did you think this ad would be effective to motivate you or someone else to be more physically
active to lose weight or be healthier?
Please use a scale from 1 to 5, where 1 is not at all effective and 5 is extremely effective. SINGLE
RESPONSE, DO NOT ROTATE
1
2
3
4
5

Q17.

Continue
Continue
Continue
Continue
Continue

Who would you say this ad is trying to reach? Please check all that apply. MULTIPLE
RESPONSE, DO NOT ROTATE
1
2
3

Q18.

Not at all effective…………………………………………
Somewhat ineffective.…………………………….………
Neither effective nor ineffective………………….………
Somewhat effective……………………………….………
Extremely effective ……………………………….……….

You……………………………………………………..…..
People like you…………………………………………….
Someone else……………………………………………..

Continue
Continue
Continue

On a scale from 1 to 5, where 1 indicates that you strongly disagree, and 5 indicates that you
strongly agree, please indicate how much you agree or disagree with each of the following
statements about this advertisement. SINGLE RESPONSE GRID FORMAT. RANDOMIZE LIST.
1
2
3
4
5
A
B
C
D
E
F
G
H
I
J
K

Strongly disagree………………………….……………….
Somewhat disagree………………………………………..
Neither agree nor disagree………………….…………….
Somewhat agree……………………………………………
Strongly agree………………………………………………

Continue
Continue
Continue
Continue
Continue

IF RESPONSE 4 OR 5 TO Q18G, ASK Q19. OTHERS SKIP TO INSTRUCTIONS BEFORE Q20.
Q19.

You mentioned that this ad grabbed your attention. What makes it stand out? OPEN
ENDED……………………………………………………………………………….…… Continue

121

BEFORE THE NEXT AD IS EVALUATED, UNTIL THE LAST AD, SHOW: Now you will see another ad to
evaluate. Once again, even if an ad is from another community or city, please rate it as if it were an ad from
your local community. Please note that we would like your reaction to each ad individually – we will not ask
you to compare one ad to any other.
[ONLY ASK Q20 ONCE A WHOLE “CAMPAIGN” IS EVALUATED]
Campaign Summary Evaluation
Q20.

Considering the impact of these ads together, please indicate how much you agree or disagree
with each statement. SINGLE RESPONSE GRID FORMAT, RANDOMIZE LIST.
1
2
3
4
5

Strongly disagree………………………………………….
Somewhat disagree……………………………………….
Neither agree nor disagree……………………………….
Somewhat agree………………………………………..…
Strongly agree…………………………………………...…

Continue
Continue
Continue
Continue
Continue

I trust the information in this set of ads.
A
This set of ads was convincing.
B
This set of ads grabbed my attention.
C
This set of ads told me something I didn’t already know.
D
The message about the health benefits of being more physically active in this set of ads
was persuasive.
E
This set of ads gave me good reasons to be more physically active.
F
This set of ads gave me good reasons to try to lose weight.
BEFORE THE SECOND CAMPAIGN SEQUENCE IS EVALUATED, SHOW: Now you will see another
series of ads to evaluate. Once again, even if an ad is from another community or city, please rate it as if it
were an ad from your local community.
INDIVIDUAL SPOT EVALUATIONS
EACH RESPONDENT WILL SEE A SET OF RANDOMLY CHOSEN INDIVIDUAL ADS. AFTER EACH AD
SHOWN, ASK Q22-Q29.
Q21.

ADS SHOWN – CODE, DO NOT DISPLAY, ADS SHOWN

122

note that we would like your reaction to each ad individually – we are not interested in comparing any of the
ads to one another.
Please click “Next” to continue.
NOTE: WHEN THE TV ADS ARE PRESENTED, PLEASE SHOW THE FOLLOWING MESSAGE ABOVE
THE SCREEN: This ad is a TV ad. Please be patient while the video loads; also note that the video may
stop to buffer from time to time. We do not expect buffering to continue for more than 30 seconds. If you
find that it is buffering too long, you can suspend the survey at any time and return to this point in the
survey simply by clicking on the original survey link.
And remember: even if an ad is from another community or city, please rate it as if it were an ad from your
local community.
NOTE: WHEN THE RADIO ADS ARE PRESENTED, PLEASE SHOW THE FOLLOWING MESSAGE
ABOVE THE SCREEN: This ad is a radio ad. Please be patient while the audio loads; also note that the
audio may stop to buffer from time to time. We do not expect buffering to continue for more than 30
seconds. If you find that it is buffering too long, you can suspend the survey at any time and return to this
point in the survey simply by clicking on the original survey link.
And remember: even if an ad is from another community or city, please rate it as if it were an ad from your
local community.
Questions for Each Ad
SHOW: Please answer the following questions about the ad you just viewed.
Q22.

If you saw or heard this message, would it get your attention? SINGLE RESPONSE, DO NOT
ROTATE
1
2

Yes……………………………………………….…………. Continue
No………………………………………………..………….. Continue

Q23.

Why or why not? OPEN ENDED………………………………..…………..

Q24.

Is this message believable? SINGLE RESPONSE, DO NOT ROTATE
1
2

Q25.

Continue

Yes………………………………………………………….
No…………………………………………………………...

Continue
Continue

Why or why not? OPEN ENDED……………………….……………………

Continue

123

Q26.

Did you think this ad would be effective to motivate you or someone else to be more physically
active to be healthier or lose weight?
Please use a scale from 1 to 5, where 1 is not at all effective and 5 is extremely effective. SINGLE
RESPONSE, DO NOT ROTATE
1
2
3
4
5

Q27.

Continue
Continue
Continue
Continue
Continue

Who would you say this ad is trying to reach? Please check all that apply. MULTIPLE RESPONSE,
DO NOT ROTATE.
1
2
3

Q28.

Not at all effective…………………………………………
Somewhat ineffective.…………………….………………
Neither effective nor ineffective………….………………
Somewhat effective……………………….………………
Extremely effective ……………………………………….

You………………………………………………...………..
People like you…………………………………………….
Someone else……………………………………………...

Continue
Continue
Continue

On a scale from 1 to 5, where 1 indicates that you strongly disagree, and 5 indicates that you
strongly agree, please indicate how much you agree or disagree with each of the following
statements about this advertisement.
1
2
3
4
5
A
B
C
D
E
F
G
H
I
J
K

Continue
Continue
Continue
Continue
Continue

IF RESPONSE 4 OR 5 TO Q28G, ASK Q29. OTHERS SKIP TO INSTRUCTIONS AFTER Q29.
Q29.

You mentioned that this ad grabbed your attention. What makes it stand out? OPEN
ENDED………………………………………………………………………………..….………. Continue

124

BEFORE THE NEXT AD IS EVALUATED, UNTIL THE LAST AD, SHOW: Now you will see another ad to
evaluate. Once again, even if an ad is from another community or city, please rate it as if it were an ad from
your local community. Please note that we would like your reaction to each ad individually – we are not
interested in comparing any of the ads to one another.
Pre-Post Questions
[Behavioral Intentions]
[CHECK S11. IF S11=1 (YES), ASK Q30. OTHERS SKIP TO Q30_2]
Q30.

Are you planning to stop drinking regular soft drinks (non-diet) or other sugary drinks within the
next 30 days? SINGLE RESPONSE, DO NOT ROTATE.
1
2

Yes……………………………………………………….….. Continue
No……………………………………………………………. Continue
[IF Q30=1 SKIP TO Q30_2. IF Q30=2 CONTINUE TO Q30_1]

Q30_1. Are you planning to cut back on regular soft drinks (non-diet) or other sugary drinks within the next
30 days? SINGLE RESPONSE, DO NOT ROTATE.
1
2

Yes………………………………………………….……….. Continue
No……………………………………………………………. Continue

Q30_2. Are you planning to be more physically active within the next 30 days? SINGLE RESPONSE, DO
NOT ROTATE.
1
2

Yes……………………………………………….…………. Continue
No……………………………………………………………. Continue

Q30_3. Are you planning to eat healthier meals and snacks within the next 30 days? SINGLE
RESPONSE, DO NOT ROTATE.
1
2
Q31.

Yes………………………………………………..…………. Continue
No……………………………………………………………. Continue

Are you planning to do something about your weight within the next 30 days? SINGLE
RESPONSE, ROTATE 1-3.
1
2
3
4

Yes, I plan to try to lose weight………………….……….
Yes, I plan to try to gain weight………………….……….
Yes, I plan to try to maintain my current weight..……….
No, I have no plans to do anything about my weight…..

Continue
Continue
Continue
Continue

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[CHECK S11. IF S11=1 (YES), ASK Q32. OTHERS SKIP TO Q32_1]
Q32.

Overall, on a scale from 1 to 5, where 1 is not at all interested and 5 is extremely interested, how
interested are you in cutting back on regular soft drinks (non-diet) or other sugary drinks? SINGLE
RESPONSE, DO NOT ROTATE.
1
2
3
4
5

Not at all interested…………………………………….…
A little interested.……………………………………….…
Somewhat interested……….………………………….…
Very interested………………………………………….…
Extremely interested …………………………………..…

Continue
Continue
Continue
Continue
Continue

Q32_1. Overall, on a scale from 1 to 5, where 1 is not at all interested and 5 is extremely interested, how
interested are you in trying to be more physically active? SINGLE RESPONSE, DO NOT ROTATE.
1
2
3
4
5

Continue
Continue
Continue
Continue
Continue

Q32_2. Overall, on a scale from 1 to 5, where 1 is not at all interested and 5 is extremely interested, how
interested are you in trying to eat healthier meals and snacks? SINGLE RESPONSE, DO NOT
ROTATE.
1
2
3
4
5

Not at all interested……………………………………..…
A little interested.………………………………………..…
Somewhat interested……….……………………………..
Very interested……………………………………………..
Extremely interested …………………………………...…

Continue
Continue
Continue
Continue
Continue

[THERE IS NO Q33]
Q34.

Thinking about the next six months, how likely are you to…? Please use a scale from 1 to 5, where
1 is not at all likely and 5 is extremely likely. SINGLE RESPONSE GRID FORMAT, RANDOMIZE
LIST
1
2
3
4
5
A
B
C

Not at all likely……………………………………………..
Somewhat unlikely..………………………………………
Neither likely nor unlikely..…………………………….…
Somewhat likely..…………………………………………
Extremely likely …………………………………………..

Continue
Continue
Continue
Continue
Continue

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[Self-Efficacy Questions]
Q35.

Q36.

Continue
Continue
Continue
Continue
Continue

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[Community Attitudes]
Q37.
1
2
3

Which of the following statements best describes how you think the problem of obesity should be
solved in your community? SINGLE RESPONSE, ROTATE 1-2.
Obesity is an individual problem that is best solved by people taking personal
responsibility for what they eat and how physically active they are………………………… Continue
Obesity is a community problem that is best solved by people working together
to make it easier for everyone to eat healthy foods and be physically active……………... Continue
Obesity is both an individual and community problem that is best solved by people taking personal
responsibility for what they eat and how physically active they are, and the community working
together to make these behaviors easier to do……………….…………………………….… Continue

CLASSIFICATION
SHOW: You’re almost done! These last few questions are for classification purposes only and will be used
for analyzing the results of the survey in total. They will not be identified with you personally.
C1.

Has a healthcare professional ever told you that you are overweight or at risk for being
overweight? SINGLE RESPONSE, DO NOT ROTATE
1
2
3

C2.

Continue
Continue
Continue

Has anyone else in your household been identified by a health care professional as being
overweight or at risk for being overweight? SINGLE RESPONSE DO NOT ROTATE
1
2
3

C3.

Yes……………………………………………………………….
No………………………………………………………………...
Don’t know / not sure ………………………………….….

Yes……………………………………………………………….. Continue
No……………………………………………………………...…. Continue
Don’t know / not sure ………………………………………..…. Continue

What is your current occupational status? Are you…? Please select the option that best applies to
you. SINGLE RESPONSE, DO NOT ROTATE.
1
2
3
4
5
6
7
8
10

Employed full time…………………………………………..….
Employed part time…………………………………………….
Unemployed…………………………………………………….
Homemaker……………………………………………………..
Student ………………………………………………..……......
Retired ………………………………………………..……...….
Disabled ………………………………………………..…...…..
Other (Please specify: _________)………………..……...….
Prefer not to answer……..…………………………………..….

Continue
Continue
Continue
Continue
Continue
Continue
Continue
Continue
Continue

128

C4.

What is your marital status? SINGLE RESPONSE, ROTATE 1-6.
1
2
3
4
5
6
8

C5.

Enter number: [Numeric Response] …………………………..… Continue
Prefer not to answer [Check Box]……..………………………….. Continue

What is your household’s total income from all sources before taxes? SINGLE RESPONSE, DO
NOT ROTATE
1
2
3
4
5
6
7
8
9

C7.

Continue
Continue
Continue
Continue
Continue
Continue
Continue

How many children (under age 18) live in your household?
1
2

C6.

Married …………………………………………………
Unmarried living with a partner………………………
Divorced ………………………………………………..
Widowed ……………………………………………….
Separated……………………………………………….
Single, never been married …………………………..
Prefer not to answer……..…………………………….

Under $20,000……..…………………………….…………..……...
$20,000 to $29,999 .…………………………….………..………...
$30,000 to $39,999 .…………………………….……..…………...
$40,000 to $49,999 .…………………………….…..……………...
$50,000 to $74,999 .…………………………….…..……………...
$75,000 to $99,999 .………………………………....………...…...
$100,000 to $199,999 .…………………………………………..…
$200,000 or more.……………………..………………………...….
Prefer not to answer.…………………………….………………….

Continue
Continue
Continue
Continue
Continue
Continue
Continue
Continue
Continue

In the following list of items, please indicate which devices you currently use or own. MULTIPLE
RESPONSE, ROTATE LIST.
1
2
3
4
5
6

A desktop computer…………………………………………….…… Continue
A laptop computer…………………………………………………… Continue
A smartphone, such as an iPhone, BlackBerry, Android, Windows phone, etc.
………………………………………………………………….……… Continue
A tablet, such as an iPad, Kindle Fire, Nook Color, Motorola Xoom, etc.
………………………………………………………………….……… Continue
An iPod or other mp3 player ……………………………………...… Continue
None of these – EXCLUSIVE - ANCHOR

SHOW: Thank you for your time. Please click “OK” to confirm your participation.

129

Attachment 3g: Screen Captures of Online Survey for Physical Activity for Hispanic Audiences (English-speaking)
Community Health Media Center – Testing Educational Campaign
Materials with African American and Hispanic Audiences
Screenshot – Online Survey Start Screen

130

131

132

Screenshot – Online Survey Question Q1_2

133

Screenshot - Online Survey Question Q1_3

134

Screenshot – Online Survey Question Q2

135

Screenshot – Online Survey Question Q3

136

Screenshot – Online Survey Question Q3_1

137

Screenshot – Online Survey Question Q3_2

138

Screenshot – Online Survey Question Q4

139

Screenshot – Online Survey Question 4_1

140

Screenshot – Online Survey Question Q4_2

141

142

{Note to reviewers: There is no Q6}
Screenshot – Online Survey Question Q7

143

Screenshot – Online Survey Question Q8

144

Screenshot – Online Survey Question Q9

145

Screenshot – Online Survey Question Q10

146

{Note to reviewers: At this point, most respondents will be shown a set of ads (TV, radio and/or print) that
correspond to a discrete campaign (randomly chosen). Others will be shown randomly chosen individual ads that
do not correspond to a discrete campaign. After each ad is shown, they will be asked Q12-Q19. }
Screenshot: Initial Screen for Ad Evaluations

147

148

Screenshot: Ad Survey Question Introduction Page

149

Screenshot – Online Survey Question Q12

150

Screenshot – Online Survey Question Q13

151

Screenshot – Online Survey Question Q14

152

Screenshot – Online Survey Question Q15

153

Screenshot – Online Survey Question Q16

154

Screenshot – Online Survey Question Q17

155

Screenshot – Online Survey Question Q18

156

157

Screenshot: Transition Page before Each Ad

158

{Note to reviewers: Q20 below will only be shown if respondents have evaluated individual ads that together
comprise a campaign.}
Screenshot – Online Survey Question Q20

159

160

161

162

Screenshot – Online Survey Question Q30_2

163

Screenshot – Online Survey Question Q30_3

164

Screenshot – Online Survey Question Q31

165

{Note to reviewers: Only respondents who selected “yes” for screener QS11, “did you drink any regular soft drinks
(non-diet) or other sugary drinks?,” will be shown the following screen (Q32). Those who responded “no” to QS11
on the screener will skip to Q32_1.}
Screenshot – Online Survey Question Q32

166

Screenshot – Online Survey Question Q32_1

167

Screenshot – Online Survey Question Q32_2

168

Screenshot – Online Survey Question Q34

169

Screenshot – Online Survey Question Q35

170

Screenshot – Online Survey Question Q36

171

Screenshot – Online Survey Question Q37

172

Screenshot: Initial Screen for Classification Questions

173

Screenshot – Online Survey Question C1

174

Screenshot – Online Survey Question C2

175

Screenshot – Online Survey Question C3

176

Screenshot – Online Survey Question C4

177

Screenshot – Online Survey Question C5

178

Screenshot – Online Survey Question C6

179

Screenshot – Online Survey Question C7

180

Screenshot – Survey End Page

181

Form Approved
OMB No. 0920-0572
Expiration Date: 2/28/2015

Attachment 3h: Online Survey for Healthy Foods
for Hispanic Audiences (English-speaking)
Community Health Media Center – Testing Educational Campaign
Materials with African American and Hispanic Audiences
Introduction
SHOW: About this online survey: Thank you for answering these questions. You are qualified to
participate in this online survey, which is being conducted on behalf of the Centers for Disease
Control and Prevention, sometimes referred to as CDC, in Atlanta. The online survey will take
about 22 minutes to complete. In this online survey, you are going to be shown sample
advertisements and asked to share your honest opinions about them.
Your responses will be entered into a database and will only be seen by researchers associated
with this online survey. Your answers will be kept secure to the extent permitted by law. There will
be no risk to you. You may stop at any time. You will receive your gift, as it is explained in your
online survey invitation, after completing the online survey.
If you have any questions about this online survey or about your rights as an online survey
participant, please email them to StudyInfo@fhi360.org.
By clicking 'Next,' I am agreeing to the above project description.
Public Reporting Burden Statement
Public reporting burden of this collection of information is estimated to average 22 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; ATTN: PRA (0920-0572).

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