Longitudinal Cohort - First post-test evaluation survey

NOTICE: Public reporting burden (or time) for this collection of information is estimated to average 4 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to PRAstaff@FDA.HHS.GOV. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is xxxx-xxxx.

OMB No.: xxxx-xxxx OMB Exp. Date: xx/xx/xx

RESIDENT [DATE]

[ADDRESS]

RTI International has been conducting a nationwide survey for the Food and Drug Administration on tobacco. Our records indicate that a [AGE] year old [GENDER] in your household was interviewed. We would appreciate it if [HE/SHE] would take a moment to complete the following questions about [HIS/HER] experience.

This information is only used to verify the quality of our interviewer’s performance.

1. Were you interviewed in-person or over the telephone?

In-person ___ Over the telephone___

2. Did the interviewer provide you with a laptop computer for you to enter some of your responses?

Yes___

No___ Please explain:_________________________________________________________________

Yes___ No___

3. Did you receive a cash incentive for your participation?

Yes___ No___

If yes, how much were you given? $_____

4. Was the interviewer professional and courteous?

Yes___

No___ Please describe how our interviewer could improve his/her behavior: _____________________

__________________________________________________________________________________________

__________________________________________________________________________________________

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

Sincerely,

National Field Director