Parent Of Youth Baseline Survey Participants

Attachment 3: Parent or Guardian Screener and Baseline Instrument

Form Approved
OMB No. 0910-0753
Exp. Date 10/31/2016

Parent/Guardian Screener and Survey: FDA Health and Media Study

Subjects for Questionnaire:
Study Screener

Section A: Home Media Environment
Section B: Environment and Demographics
Section C: Tobacco Use

Section D: Youth Topics

Parent or Guardian Screener

SCR1.

Hello, my name is [FI NAME] with RTI International in North Carolina. We are conducting a national study sponsored by the U.S. Food and Drug Administration.

You should have received a letter explaining the study.

[IF NEEDED] HAND R COPY OF LETTER EXPLAINING THE STUDY.

NEXT [GOTO SCR2]

SCR2.

First, let me verify: do you live here?

1 YES

2 NO

DK/ REF

[IF SCR2=YES]

SCR3.

IF NECESSARY (Are you 18 or older?)

1 YES

2 NO

[IF (SCR2=2 OR SCR2=DK/REF )OR (SCR3=1 OR SCR3=/DK/REF)]

SCR3a.

I need to speak with someone who is 18 or older and lives here. May I speak with someone who can help me?

1 YES, PERSON IS AVAILABLE

2 YES, BUT NEED TO SCHEDULE

3 NO, NO ONE LIVING HERE 18 OR OLDER

DK/ REF

PROGRAMMER: IF SCR3a=1 THEN SKIP BACK TO SCR1. IF SCR3a=2, GOTO SCR15a. IF SCR3a=3 THEN SKIP TO SCR17..

SCR4.

ADDRESS VERIFICATION

First, I need to verify -- is this

STREET: (NUMBER AND STREET)

CITY: (CITY)

STATE: (STATE)

ZIP: (ZIP)

1 Address Is Correct [GOTO SCR5.]

3 FI At Wrong Address [BREAKOFF SELECT CORRECT CASE]

SCR5.

STUDY DESCRIPTION

GIVE PERSON STUDY DESCRIPTION AND SAY

I’d like you to follow along with me as I read the following statement. It describes the survey and assures the privacy to the fullest extent allowable by law of any information you provide. It also explains that your answers are used for statistical purposes only and that your participation is voluntary.

STUDY DESCRIPTION TEXT

Your address is one of several in this area randomly chosen for the U.S. Food and Drug Administration (FDA) Health and Media study. This study, sponsored by the FDA, is collecting information from boys across the United States about their attitudes related to health, health behaviors, and advertisements they may have seen on TV and/or online.

You cannot be identified by any of the information you give to us. Your name and address will never be connected to your answers. Also, federal law requires that we keep all of your responses private to the fullest extent allowable by law. Any data you provide will only be used for statistical purposes and reported in aggregate form.

The screening questions take just a few minutes to determine if anyone in your household is eligible. One or possibly more children in your household may be asked to voluntarily participate in the survey. If anyone is chosen, the interview itself will take approximately 30-40 minutes. We would also like to ask you a few questions about your household’s characteristics and media use. You and your child can refuse to answer any questions, and you can quit at any time. Your child will be offered $20 upon completing the interview.

We will conduct three follow-up surveys every eight months to understand changes in health-related attitudes and behaviors over time. Each of these additional interviews will also be completely voluntary. If your child participates in future rounds, he will be offered a $20 incentive for participating in each of the three in-person interviews.

If you have any questions about the study, please contact the project representative Melissa Helton, at 800 334-8571 extension 27168. If you have questions about your rights as a study participant, call toll-free: RTI’s Office of Human Research Protections at 1-866-214-2043.

Thank you for your cooperation and time.

Next SCR7

SCR7.

TOTAL SDU MEMBERS

Including yourself, how many adults age 18 and older usually live in this household?

_____ [RANGE 1-20]

[PROGRAMMER: IF SCR7 = 1, GOTO SCR7_CONFIRM.

IF SCR7>1, GOTO SCR21.]

SCR7_CONFRM

IS THERE ONLY 1 PERSON IN THIS HOUSEHOLD?

1 YES

2 NO

IF SCR7_CONFRM = 1, GOTO SCR21.

IF SCR7_CONFRM = 2, GO BACK TO SCR7 TO CORRECT

SCR21.

What is your relationship status?

1 Married

2 Living with a partner

3 Divorced

4 Widowed

5 Separated

6 Single, that is, never married and not now living with a partner

SCR22.

What is the highest grade or year of school you completed?

INTERVIEWER: DO NOT READ RESPONSE OPTIONS. CODE ANSWER BASED ON RESPONSE.

1 NEVER ATTENDED SCHOOL OR ONLY KINDERGARTEN

2 ELEMENTARY SCHOOL (GRADES 1 THROUGH 8)

3 HIGH SCHOOL (GRADES 9-12, NO DIPLOMA)

4 HIGH SCHOOL GRADUATE OR EQUIVALENT

5 SOME COLLEGE (1-4 YEARS, NO DEGREE)

6 ASSOCIATE’S DEGREE (AA, AS)

7 BACHELOR’S DEGREE (BA, BS, AB)

8 GRADUATE OR PROFESSIONAL DEGREE

SCR23.

The next question is about the total income of YOUR HOUSEHOLD for the PAST 12 MONTHS.

Thinking about all members of your household, what is the combined annual income, meaning the total pre-tax income from all sources earned in the past year?

(IF NECESSARY: Please include your income PLUS the income of all members living in your household (including cohabiting partners and armed forces members living at home). Please count income BEFORE TAXES and from all sources (such as wages, salaries, tips, net income from a business, interest, dividends, child support, alimony, and Social Security, public assistance, pensions, or retirement benefits).)

1 Less than $10,000

2 $10,000 to under $30,000

3 $30,000 to under $50,000

4 $50,000 to under $70,000

5 $70,000 to under 110,000

6 $110,000 or more

SCR24.

Are you currently working or not working?

1. Working

2. Not working

SCR24a. [IF SCR24=1] Are you…

1 Working full-time as a paid employee

2 Working full-time, self-employed, or

3 Working part-time

SCR24b. [IF SCR24=2] Are you…

1. On a temporary layoff from a job

2. Looking for work

3. Retired

4. Disabled

5. Not working for another reason

SCR25.

At this house, apartment, or mobile home – do you or any member of this household subscribe to the Internet using

1 Dial-up service

2 DSL service

3 Cable modem service

4 Fiber optic service

5 Mobile broadband plan for a computer or a cell phone

6 Satellite internet service

7 Some other service

8 No internet service

SCR26.

What type of health care coverage do you use to pay for most of your medical care?

1 Private insurance coverage

2 Medicare

3 Medicaid or Medical Assistance

4 Military, CHAMPUS, TriCare, or the VA

5 Indian Health Service

6 Other

7 None

SCR27.

Do any of the adults living in the home currently smoke cigarettes?

1. YES

2. NO

SCR28.

Do any of the adults living in the home currently use dip, chewing tobacco, snuff, or snus, such as Copenhagen, Grizzly, Skoal, or Camel Snus?

1. YES

2. NO

PROGRAMMER: IF SCR7 = 1 AND SCR7_CONFIRM=1, GO TO SCR17.

SCR7a.

How many youth ages 0 to 17 live here now?

_____ [RANGE 0-9]

DK/REF

PROGRAMMER:

IF SCR7a = 1, GO TO SCR8a.

IF SCR7a>1, GO TO SCR8a. Loop SCR8a as many times as SCR7a (i.e., the number of youths ages 0-16 living in household) with a max of 9 times.

IF SCR7a=0, GOTO SCR17

IF SCR7a = DK/ REF SKIP TO SCR7b

SCR7b.

I’m sorry but I’m unable to determine whether anyone in your household is eligible. Is there someone else who lives in this household that I can speak with?

1 YES

2 YES, BUT NEED TO SCHEDULE

3 NO

DK/REF

PROGRAMMER:

IF SCR7b = 1 GO BACK TO SCR1.

IF SCR7b = 2 THEN GOTO SCR15a.

IF SCR7b = 3 OR SCR7b=DK/REF, GOTO SCR18.

[ASK IF SCR7a > 0]

SCR8a.

YOUTH ROSTER INTRO

[IF SCR7a=1, use:

“Please tell me the first name, nickname, or initials of the child between the ages of 0 and 17. We ask for the name to help you keep track of household members as you answer the questions and it will not be recorded by the study.”]

[IF SCR7a>1, use:

[IF SCR7a<=9,

FILL_SCR8b1= “”.

IF SCR7a>9,

FILL_SCR8b1= ”If there are more than 9 children ages 0-17, we are only going to ask you about the oldest 9.”]

[First iteration, FILL_SCR8b2= “”.

Second iteration, FILL_SCR8b2= “second”.

Third iteration, FILL_SCR8b2= “third”.

Fourth iteration, FILL_SCR8b2= “fourth”.

Fifth iteration, FILL_SCR8b2= “fifth”.

Sixth iteration, FILL_SCR8b2= “sixth”.

Seventh iteration, FILL_SCR8b2= “seventh”.

Eighth iteration, FILL_SCR8b2= “eighth”.

Ninth iteration, FILL_SCR8b2= “ninth”.]

PROGRAMMER: First pass through/ first iteration:

“We would like to know about the children ages 0-17 living in your household, starting with the oldest and ending with the youngest. [FILL_SCR8b1]

Please tell me the first name, nickname, or initials of the oldest child between the ages of 0 and 17. We ask for the name to help you keep track of household members as you answer the questions and it will not be recorded by the study.”

PROGRAMMER: SECOND to Ninth iteration:

“What is the first name, nickname, or initials of the [FILL_SCR8b2] oldest child between the ages of 0 and 17?

INTERVIEWER IF NEEDED: (We ask for the name to help you keep track of household members as you answer the questions and it will not be recorded by the study.)

SCR8a1_n

____________________ [ALLOW 20 CHARACTERS]

SCR8a2_n

How old is [SCR8a1_n]?

_____[RANGE 0-17]

DK/REF

[ASK IF SCR8a2_n is 11-16]

SCR8a3_n

Is [SCR8a1_n] male or female?

1 MALE

2 FEMALE

DK/REF

[PROGRAMMER:

WHEN NAMING VARIABLES, MAKE SURE that _n TAKES INTO ACCOUNT THE NUMBER OF ITERATION. FOR EXAMPLE, THE SIXTH ITERATION HAS SCR8a1_6, SCR8a2_6, AND SCR8a3_6. NINTH ITERATION HAS SCR8a1_9, SCR8a2_9, AND SCR8a3_9.

LET NAME_ELIG_n= NAME OF CHILD [SCR8a1_n] THAT SATISFIES THE CONDITION [SCR8a2=11-16] AND [SCR8a3=1].

CALCULATE THE FOLLOWING:

CALC_ELIG= NUMBER OF CHILDREN WHO [SCR8a2_n=11-16] AND [SCR8a3_n=1]

IF CALC_ELIG=0, GOTO SCR17

IF CALC_ELIG=1, GOTO SCR9.

IF CALC_ELIG>1, GOTO SCR10.]

[ASK IF CALC_ELIG=1]

SCR9.

ONE ELIGIBLE YOUTH

Thank you. It turns out that [NAME_ELIG] is eligible for the survey.

To proceed, I need to speak with the parent or legal guardian of [NAME_ELIG].

PRESS 1 TO CONTINUE.

SCR9a.

What is the first name, nickname, or initials of the parent or legal guardian of [NAME_ELIG]? Again, we ask for the name to help keep track of household members as you answer the questions and it will not be recorded by the study.”

__________ [ALLOW 20 CHARACTERS]

DK/REF

PROGRAMMER: IF SCR9a = DK/REF, SOFT PROMPT: “Please let us know the first name, nickname, or initials of the parent or legal guardian of [NAME_ELIG]. We only ask this to help keep track of household members as we go through the questions. All information collected as part of the study will be kept private to the fullest extent allowable by law, and nothing you tell us will be reported with your name.”

IF SCR9a= DK/ REF the second time, GOTO SCR9c.

SCR9b.

Would that be you?

1 YES

2 NO

DK/REF

IF SCR9b = 1, GOTO SCR12.

IF SCR9b =2, GOTO SCR13.

SCR9c.

Can I talk to the parent or legal guardian of [NAME_ELIG]?

1. YES, CURRENT RESPONDENT IS THE PARENT OR LEGAL GUARDIAN

2. YES, DIFFERENT ADULT CAME FORWARD

3 NOT NOW, BUT LATER

4 NO, REFUSAL TO INTERVIEW

PROGRAMMER: IF SCR9c=1, GOTO SCR12. IF SCR9c=2, GOTO SCR14. IF SCR9c = 3, GOTO SCR15a. IF SCR9c=4, GOTO SCR16.

[ASK IF CALC_ELIG>1]

SCR10.

MORE THAN ONE ELIGIBLE YOUTH

Thank you. It turns out that you have children who are eligible for the survey.

To proceed, I need to speak with the parent or legal guardian of the children.

INTERVIEWER: WAIT FOR ONE PARENT OR LEGAL GUARDIAN TO COME FORWARD.

GOTO SCR10a

eeeeSCR10a.

Do the children have the same parent or legal guardian?

1 YES

2 NO

DK/ REF

IF SCR10a = 1, GOTO SCR10b.

IF SCR10a = 2 OR SCR10a=DK/REF, GOTO SCR11.

[ASK IF SCR10a=1]

SCR10b.

What is the first name, nickname, or initials of the parent and legal guardian of the children? Again, we ask for the name to help keep track of household members as you answer the questions and it will not be recorded by the study.

__________ [ALLOW 20 CHARACTERS]

DK/REF

PROGRAMMER: IF SCR10b = DK/REF, SOFT PROMPT: “Please let us know the first name, nickname, or initials of the parent or legal guardian of the children. We only ask this to help keep track of household members as we go through the questions. All information collected as part of the study will be kept private to the fullest extent allowable by law, and nothing you tell us will be reported with your name.”

IF SCR10b= DK/ REF the second time, GOTO SCR10d.

SCR10c.

Would that be you?

1 YES

2 NO

DK/REF

IF SCR10c = 1, GOTO SCR12

IF SCR10c = 2, GOTO SCR13

SCR10d.

Can I talk to the parent or legal guardian of the children?

1. YES, CURRENT RESPONDENT IS THE PARENT OR LEGAL GUARDIAN

2. YES, DIFFERENT ADULT CAME FORWARD

3 NOT NOW, BUT LATER

4 NO, REFUSAL TO INTERVIEW

PROGRAMMER: IF SCR10d=1, GOTO SCR12. IF SCR10d=2, GOTO SCR14. IF SCR10d = 3, GOTO SCR15a. IF SCR10d=4, GOTO SCR16.

[ASK IF SCR10a=2]

SCR11.

[PROGRAMMER: START WITH NAME_ELIG_1, NAME_ELIG_2, AND SO ON.]

Please tell me the first name, nickname, or initials of the parent or legal guardian of the following children. Again, we ask for the name to help keep track of household members as you answer the questions and it will not be recorded by the study.

SCR11_1	[NAME_ELIG_1]	[ALLOW 20 CHARACTERS]	DK/REF
SCR11_2	[NAME_ELIG_2]	[ALLOW 20 CHARACTERS]	DK/REF
SCR11_3	[NAME_ELIG_3]	[ALLOW 20 CHARACTERS]	DK/REF
SCR11_4	[NAME_ELIG_4]	[ALLOW 20 CHARACTERS]	DK/REF
SCR11_5	[NAME_ELIG_5]	[ALLOW 20 CHARACTERS]	DK/REF
SCR11_6	[NAME_ELIG_6]	[ALLOW 20 CHARACTERS]	DK/REF
SCR11_7	[NAME_ELIG_7]	[ALLOW 20 CHARACTERS]	DK/REF
SCR11_8	[NAME_ELIG_8]	[ALLOW 20 CHARACTERS]	DK/REF
SCR11_9	[NAME_ELIG_9]	[ALLOW 20 CHARACTERS]	DK/REF

[PROGRAMMER: populate the table UNTIL CALC_ELIG. so, IF CALC_ELIG=4, table will have name_elig_1 (and scr11_1) to name_elig_4 (SCR11_4).

LET i=1 TO CALC_ELIG.

IF SCR11_i = DK/REF,

SOFT PROMPT: “Please let us know the first name, nickname, or initials of the parent or legal guardian of [NAME_ELIG_i]. We only ask this to help keep track of household members as we go through the questions. All information collected as part of the study will be kept private to the fullest extent allowable by law, and nothing you tell us will be reported with your name.”

IF SCR11_i= DK/ REF THE SECOND TIME, GOTO SCR11a_i.

IF SCR11_i NE DK/REF, GOTO SCR11b_i

[IF SCR11_i=DK/ REF SECOND TIME, ASK SCR11a_i]

SCR11a_i.

Can I talk to the parent or legal guardian of [NAME_ELIG_i]?

1. YES, CURRENT RESPONDENT IS THE PARENT OR LEGAL GUARDIAN

2. YES, DIFFERENT ADULT CAME FORWARD

3 NOT NOW, BUT LATER

4 NO, REFUSAL TO INTERVIEW

PROGRAMMER: IF SCR11a_i=1, GOTO SCR12. IF SCR11a_i =2, GOTO SCR14. IF SCR11a_i = 3, GOTO SCR15a. IF SCR11a_i =4, GOTO SCR16.

[IF SCR11_i NE DK/ REF, ASK SCR11b_i]

SCR11b_i.

May I speak with [SCR11_i]?

2. YES, DIFFERENT ADULT CAME FORWARD

2 NOT NOW, BUT LATER

3 NO, REFUSAL TO INTERVIEW

DK/ REF

PROGRAMMER: : IF SCR11b_i=1, GOTO SCR12. IF SCR11b_i =2, GOTO SCR14. IF SCR11b_i = 3, GOTO SCR15a. IF SCR11b_i =4, GOTO SCR16.

[IF SCR9b =1 OR SCR9c=1 OR SCR10c = 1 OR SCR10d=1, OR SCR11a_i=1 OR SCR11b_i=1]

SCR12.

I’d like to explain more about this study and how you may be able to help us. If this is a good time, we could get started now. I will need a place to set up a laptop computer.

1 YES

2 NOT NOW, BUT LATER

3 NO, REFUSAL TO INTERVIEW

PROGRAMMER: IF SCR12=1 THEN SKIP TO SCR12a, READY-FOR-CONSENT. IF SCR12=2 THEN SKIP TO SCR12a. IF SCR12=3, SKIP TO SCR16.

[ASK IF SCR12=1 OR SCR12=2 OR SCR14=1 OR SCR14=2]

SCR12a.

[PROGRAMMER:

IF (SCR12=1 OR SCR14=1), FILL_SCR12a_1= “begin”

IF (SCR12=1 OR SCR14=1), FILL_SCR12a_1= “end”

Let i=CALC_ELIG.

IF CALC_ELIG=1, FILL_SCR12a_2= [NAME_ELIG],

IF CALC_ELIG>1 AND SCR10a=1, FILL_SCR12a_2=”the eligible youths”

IF CALC_ELIG>1 AND (SCR10a=2 OR SCR10a=DK/REF), FILL_SCR12a_2=[NAME_ELIG_i]

Before we [FILL_SCR12a_1], we need your permission for [FILL_SCR12a_2] to take the survey. All eligible youths who completes the survey will receive $20 in cash as a token of our appreciation.

INTERVIEWER: GIVE PARENT OR LEGAL GUARDIAN THE PARENT CONSENT FORM.

DID PARENT OR LEGAL GUARDIAN CONSENT?

1 YES

2 NO

PROGRAMMER: IF (SCR12=1 AND SCR12a=1) OR (SCR14=1 AND SCR12a=1) THEN SKIP TO SCR18 AND CODE AS ELIGIBLE. IF (SCR12=2 AND SCR12a=1) OR (SCR14=2 AND SCR12a=1) THEN SKIP TO SCR15a. IF SCR12a=2, SKIP TO SCR16.

[IF SCR9b = 2 OR SCR10c = 2]

SCR13.

IF CALC_ELIG=1, FILL_SCR13=NAME_ELIG.

IF CALC_ELIG>1 AND SCR10a=1, FILL_SCR13= “the children”

May I speak with [FILL_SCR13]’s parent or guardian?

1 YES

2 NOT NOW, BUT LATER

3 NO, REFUSAL TO INTERVIEW

DK/ REF

PROGRAMMER: IF SCR13=1, GOTO SCR14. IF SCR13 = 2 THEN GOTO SCR15a. IF SCR13=3, GOTO SCR16.

[IF SCR9c=2 OR SCR10d=2, OR SCR11a_i=2 OR SCR11b_i=2 OR SCR13=1]

SCR14.

PROGRAMMER: IF CALC_ELIG=1, FILL_SCR14= “your child has”.

IF CALC_ELIG>1, FILL SCR14= “your children have”.

[ONCE PARENT/GUARDIAN IS AVAILABLE]

Hello, my name is [FI_NAME] from RTI International in North Carolina. We are conducting a national study of youth to ask their opinions related to health and advertisements they may have seen on TV and online. Based on answers to the screening questions, [FILL_SCR14] been selected for the study. I’d like to explain the study and how you may be able to help us. If this is a good time, we could get started. I have some information for you about the study and I will need a place to set up a laptop computer.

1 YES

2 NOT NOW, BUT LATER

3 NO, REFUSAL TO INTERVIEW

DK/ REF

PROGRAMMER: IF SCR14=1, GOTO SCR18 AND CODE AS SC Completed – Child Selected), READY-FOR-CONSENT. IF SCR14=2, GOTO SCR15a. IF SCR14=3, GOTO SCR16.

[IF SCR3a=2 OR SCR7b=2 OR SCR9c=3 OR SCR10d=3 Or SCR11a_i=3 OR SCR11b_i=3 OR SCR12=2 OR SCR13=2 OR SCR14=2]

SCR15a-b.

Let me schedule a convenient time to come back. First what would be a good date?

ENTER MONTH AND DAY HERE; ENTER TIME ON THE NEXT SCREEN.

SCR15a MONTH ____

SCR15b DAY ____

DK/REF

PROGRAMMER: MONTH DROPDOWN 1-12. DAY DROPDOWN 1-31. DO NOT ALLOW INVALID DATES SUCH AS FEBRUARY 30, APRIL 31, JUNE 31, ETC.

[IF SCR3a=2 OR SCR7b=2 OR SCR9c=3 OR SCR10d=3 Or SCR11a_i=3 OR SCR11b_i=3 OR SCR12=2 OR SCR13=2 OR SCR14=2]

SCR15c- SCR15e.

(Let me schedule a convenient time to come back.)

What would be a good time on [SCR15a] [SCR15b]?

SCR15c HOUR ____

SCR15d MINUTES _____

SCR15e

1 AM

2 PM

DK/REF

PROGRAMMER: ALLOW HOUR 1-12. ALLOW MINUTES 00-59. LET AM AND PM BE CHECKBOXES.

[IF SCR3a=2 OR SCR7b=2 OR SCR9c=3 OR SCR10d=3 Or SCR11a_i=3 OR SCR11b_i=3 OR (SCR12=2 AND SCR12a=1) OR (SCR14=2 AND SCR12a=1) OR SCR13=2]

SCR15f.

PROGRAMMER: IF SCR3a=2 OR SCR7b=2, FILL_SCR15f= “me to return to complete the brief screening questions”

IF SCR12=2 OR SCR13=2 OR SCR14=2, FILL_SCR15f= “the interview”

IF SCR9c=3 OR SCR10d=3 Or SCR11a_i=3 OR SCR11b_i=3, FILL_SCR15f= “me to return to interview the parent or legal guardian and to get their permission to interview the eligible youths.”

Thank you for setting an appointment for [FILL_SCR15f]. I will return on [SCR15a] [SCR15b] at [SCR15c]:[SCR15d] [SCR15e].

[PROGRAMMER: UPON COMPLETING SCR15a-f,

IF (SCR12=2 AND SCR12a=1) OR (SCR14=2 AND SCR12a=1) OR SCR13=2 OR SCR9c=3 OR SCR10d=3 Or SCR11a_i=3 OR SCR11b_i=3, GOTO SCR18.

ELSE, GOTO SCRFINISH.]

[IF SCR9c=4 OR SCR10d=4 OR SCR11a_i=4 OR SCR11b_i=4 OR SCR12=3 OR SCR13=3 OR SCR13=3 OR SCR14=3]

SCR16.

Thank you for your time and consideration. I have just a few more questions if you can spare just a couple more minutes. Can you tell me more about your reasons for not participating in this study?

___________________ [ALLOW 100 CHARACTERS]

DK/REF

PROGRAMMER: UPON COMPLETING SCR16, GOTO SCR18.

[IF SCR3a=3 OR SCR7a= 0]

SCR17

I’m sorry, but based on your answers to the screening questions no one in your household is eligible to participate in this study. Thank you for taking the time to answer these screening questions. So that my supervisor may check the quality of my work, please give me just your first name and telephone number.

IF THE SR REFUSES TO ANSWER, ENTER 99

<FIRST NAME> _________ [ALLOW 20 CHARACTERS]

DK/REF

<TELEPHONE NUMBER> ___________ (APPLY 3-3-4 FORMAT)

DK/REF

SCR18.

Those are all the questions I have. Thank you for your assistance.

INTERVIEWER: THE REMAINING 2 QUESTIONS ARE TO BE RECORDED BY OBSERVATION.

PRESS NEXT TO CONTINUE

SCR19.

INTERVIEWER RECORD SCREENING RESPONDENT’S GENDER

1 MALE

2 FEMALE

SCR20.

[PROGRAMMER: ALL SCREENINGS WILL ANSWER] INTERVIEWER RECORD PRIMARY LANGUAGE USED FOR THIS SCREENING

1 ENGLISH

2 SPANISH

SCRFINISH

TAP “EXIT” TO EXIT TO CASE MANAGEMENT SYSTEM (CMS) OR “BACK” TO GO BACK.

PRESS 1 TO EXIT SCREENER

PROGRAMMER: MAKE SURE THAT IN THE CASE OF MULTIPLE CHILDREN WITH DIFFERENT SETS OF PARENTS, THE SCREENER DOES NOT END AFTER THE FIRST PARENT. IT SHOULD GO BACK TO SCR11a_i or SCR11b_i (DEPENDING ON THE CONTEXT).

Programming Specifications 10-23-2015

Programmer Notes:

• Program should capture time/date stamp at start of survey.

• Section headings should not appear in the instrument.

• Variable names should not appear before the question on the screen. They should be in a corner and will be used for testing purposes.

• In the case of a table such as A1, variables A1_1- A1_10 could instead be numbered 1-5.

• Response option boxes (i.e. ₁) are for display only. They should not have the number right next to it on the screen.

• In a table, when the header has “1 Definitely Yes,” “2 Probably Yes,” etc. make sure that the numbers do not appear in the instrument. These are for back-end purposes only.

• Only one question should appear per screen, except where there is a grid, or an intro.

• Make sure that all questions should fit in a screen. Respondents should not have to scroll on a given page.

• Make sure that the “Prefer not to answer” response is only shown when a respondent tries to skip a question. First, a soft check pop-up screen will appear that says “This question is important to the survey. If you meant to leave it blank, just continue. Otherwise, please answer it.” After the screen shows up, show the response options with the “Prefer not to answer” option.

• Make sure that the “Prefer not to answer” response option is clearly marked that it is separate from the other response options. One way, we can do this is by having an extra space between the response options and the “Prefer not to answer” response option. See A2 as an example for single items. See A1 for table formats.

• Respondents may not move backward within a survey. The testing version of the survey should have a Previous button to allow testers to back up.

• Range checks will be a soft check unless otherwise noted.

• For all entries that are keyed numbers, only accept blank or numeric values. If an alpha is keyed and there is no specific numeric range check, please display hard check, “Please enter a number.” Otherwise, the check will also include the valid numeric range.

• For all radio button questions, include an “uncheck” box.

• Respondents will be permitted to “pause” a survey at any point in the survey and then return to complete the survey at a later time. This should not have implications for programming.

• “Next” buttons will be displayed on every survey screen as appropriate.

• All images should be arrange in such a way that focus on usability and layout. Images should be aligned and of similar sizes as one another.

Fills:

IF CALC_ELIG=1, THEN YOUTH_NAME=[NAME_ELIG].

IF CALC_ELIG>1, THEN YOUTH_NAME_i=[NAME_ELIG_i].

INTRO

PROGRAMMER: IF CALC_ELIG=1, FILL_INTRO= “your child has”.

IF CALC_ELIG>1, FILL INTRO= “your children have”.

We are conducting a national study of youth to ask their opinions related to health and advertisements they may have seen on TV and online. Based on answers to the screening questions, [FILL_INTRO] been selected for the study. We would like to ask you a few questions about your household’s characteristics and media use. You can refuse to answer any questions, and you can quit at any time.

If you have any questions about the study, please contact the project representative Melissa Helton, at 800 334-8571 extension 27168. If you have questions about your rights as a study participant, call toll-free: RTI’s Office of Human Research Protections at 1-866-214-2043.

INTRO1

We will be asking you about media consumption of [CHILD NAME]. Would you consider yourself to be knowledgeable in responding to items about the [CHILD NAME]?

₁ Yes.

₂ No.

[IF INTRO1=2]

INTRO2

PROGRAMMER: IF CALC_ELIG=1, FILL_INTRO2= “CHILD 1 NAME”.

IF CALC_ELIG>1, FILL INTRO2= “CHILD 1 NAME AND CHILD 2 NAME, ETC”.

₁ Yes.

₂ No.

Section A: Home Media Environment

A1. How many of the following items are there in your home?

	0 Items	1	2	3	4 or more	99 Prefer not to answer
A1_1. TVs?	0	1	2	3	9	99
A1_4. Access to paid streaming services such as Netflix or Hulu Plus?	0	1	2	3	9	99
A1_7. Tablet computers like an iPad, Samsung Galaxy, Motorola Xoom, or Kindle Fire?	0	1	2	3	9	99
A1_8. Desktop or laptop computers?	0	1	2	3	9	99
A1_10. Video game players that hook up to TV (Xbox, Wii, PSP) and handheld players (Nintendo DS, Sony PSP, iPod)	0	1	2	3	9	99

A2. [IF A1_1 NE 0] Is a TV usually kept on in your home, even when no one is watching?

₁ Yes, we usually keep a TV on.

₂ No, we do not keep a TV on.

₉ Prefer not to answer

A3. [IF A1_1 NE 0] In your home, is the TV usually on during meals, or not?

₁ Yes, the TV is usually on during meals.

₂ No, the TV is not usually on during meals.

₉ Prefer not to answer

A4. During the past 7 days, how many meals did all or most of your family sit down and eat together at home?”

_______ Number of days [RANGE: 0-7]

₉ Prefer not to answer

Section B: Demographics

B2 How many children aged 17 or younger live in your household 6 months or more during the year?

_______ Number of Children

₉ Prefer not to answer

B3 Are you of Hispanic, Latino/a, or Spanish origin?

₁ No, not of Hispanic, Latino/a, or Spanish origin

₂ Yes, Mexican American, Chicano/a

₃ Yes, Puerto Rican

₄ Yes, Cuban

₅ Yes, another Hispanic, Latino/a, or Spanish origin

₉ Prefer not to answer

B4 What race or races do you consider yourself to be? Select all that apply.

	1 Yes
B4_1. White	1
B4_2. Black or African American	1
B4_3. American Indian or Alaska Native	1
B4_4. Asian	1
B4_10. Native Hawaiian or other Pacific Islander	1
B4_13. Other	1

₉ Prefer not to answer

B9. Do you currently own or rent your home?

₁ Own

₂ Rent

₃ Something else

₉₉ Prefer not to answer

Section C: Tobacco Use

C1. About how many cigarettes have you smoked in your entire life? Your best guess is fine.

₁ 0 cigarettes, not even 1 or 2 puffs [GOTO C1b]

₂ 1 or more puffs, but never a whole cigarette [GOTO C1b]

₃ 1 cigarette

₄ 2 to 5 cigarettes

₅ 6 to 15 cigarettes (about half a pack)

₆ 16 to 25 cigarettes (about a pack)

₆ 26 to 99 cigarettes (more than a pack but less than 5 packs)

₇ 100 or more cigarettes (5 or more packs)

₉ Prefer not to answer

PROGRAMMER: IF C1=1, GOTO C1b.

C1a. Do you now smoke every day, some days, or not at all?

₁ I smoke every day

₂ I smoke on some days

₃ I do not smoke at all

₉ Prefer not to answer

C1b. Does your spouse or partner now smoke every day, some days, or not at all?

₁ Smokes every day

₂ Smokes on some days

₃ Does not smoke at all

₄ I do not have a spouse or partner.

₉ Prefer not to answer

The next questions are about the use of tobacco other than cigarettes.

C6. Have you ever used smokeless tobacco, such as chewing tobacco, snuff, or dip?

₁ Yes

₂ No

₉ Prefer not to answer

PROGRAMMER: IF C6=2, GOTO C8.

C7. Do you now use smokeless tobacco, such as chewing tobacco, snuff, or dip, every day, some days, or not at all?

₁ I use smokeless tobacco every day

₂ I use smokeless tobacco on some days

₃ I do not use smokeless tobacco at all

₉ Prefer not to answer

C8. Does your spouse or partner use smokeless tobacco such as chewing tobacco, snuff, or dip, every day, some days, or not at all?

₁ Spouse or partner uses smokeless tobacco every day

₂ Spouse or partner uses smokeless tobacco on some days

₃ Spouse or partner does not use smokeless tobacco at all

₄ I do not have a spouse or partner.

₉ Prefer not to answer

C14. Which statement best describes the rules about smoking in your home? Would you say…

₁ Smoking is not allowed anywhere inside your home

₂ Smoking is allowed in some places or at some times

₃ Smoking is allowed anywhere inside the home

₄ There are no rules about smoking inside the home

₉ Prefer not to answer

Section D: Youth Topics

D0. To the best of your knowledge, has the child [YOUTH NAME] used any of the following during the past 30 days…? Select all that apply.

₁ Cigarettes

₂ Smokeless tobacco, such as chewing tobacco, snuff, snus (rhymes with goose) or dip, such as Copenhagen, Skoal, Grizzly, Kodiak, and Red Seal

₃ Cigars, cigarillos, or little cigars such as Swisher Sweets, White Owl, Cheyenne, Dutch Masters, Garcia Y Vega or Middleton’s

₄ Any other form of tobacco

₅ Electronic cigarettes (e-cigs), e-hookahs, vape pens, hookah pens, or personal vaporizers such as Fin, NJOY, Blu, e-Go, and Vuse.

₆ No, [YOUTH NAME] has not used any form of tobacco during the past 30 days

₉ Prefer not to answer

D1. Does [YOUTH NAME] have a cell phone?

₁ Yes, [YOUTH NAME] has his own cell phone

₂ Yes, [YOUTH NAME] shares a phone or uses someone else’s in our home

₃ No, [YOUTH NAME] does not own or use a cell phone.

₉ Prefer not to answer

[ASK IF D1 = 1 OR 2]

D1a. Do you have rules about [YOUTH NAME]’s use of cell phones?

₁ Yes

₂ No

₉ Prefer not to answer

[ASK IF D1a = 1]

D1b. Do you limit the times of day [YOUTH NAME] can use a cell phone?

₁ Yes

₂ No

₉ Prefer not to answer

[ASK IF D1 = 1 OR 2]

D1c. Do you have other rules or restrictions on how [YOUTH NAME] uses a cell phone?

₁ Yes

₂ No

₉ Prefer not to answer

[ASK IF D1a, D1b, OR D1c = 1]

D1d. Have you told [YOUTH NAME] what the consequences are for not following the rules (e.g., taking away the phone)?

₁ Yes

₂ No

₉ Prefer not to answer

[ASK IF D1a, D1b, D1c, OR D1d = 1]

D1e. Have you ever had to give [YOUTH NAME] consequences for not following the rules about cell phone use?

₁ Yes

₂ No

₉ Prefer not to answer

(ASK if D1 = 1 or 2)

D2. Some cell phones are called 'smartphones' because of certain features they have. Is [YOUTH NAME]’s cell phone a smartphone, such as an iPhone or Android?

₁ Yes

₂ No

₃ I don’t know

₉ Prefer not to answer

D3. Which of these best describes where [YOUTH NAME] sleeps at night?

₁ In a bedroom of his own

₂ In a bedroom he shares with someone else

₃ In another room

₉ Prefer not to answer

[ASK IF D3=3]

D3_1. Please specify which other room [YOUTH NAME] sleeps at.

__________

PROGRAMMER: ALLOW 20 CHARACTERS.

D4_1. [IF D3=1 OR 2 AND A1_1>0] Does [YOUTH NAME] have a TV in his bedroom?

₁ Yes

₂ No

₂ I don’t know

₉ Prefer not to answer

D4_2. [IF D3=1 OR 2 AND A1_4>0] Does [YOUTH NAME] have access to paid streaming services such as Netflix or Hulu Plus in his bedroom?

₁ Yes

₂ No

₂ I don’t know

₉ Prefer not to answer

D4_3. [IF D3=1 OR 2 AND A1_7>0] Does [YOUTH NAME] ever have tablet computers like an iPad, Samsung Galaxy, Motorola Xoom, or Kindle Fire in his bedroom?

₁ Yes

₂ No

₂ I don’t know

₉ Prefer not to answer

D4_4. [IF D3=1 OR 2 AND A1_8>0] Does [YOUTH NAME] ever have desktop or laptop computers in his bedroom?

₁ Yes

₂ No

₂ I don’t know

₉ Prefer not to answer

D4_5. [IF D3=1 OR 2 AND A1_10>0] Does [YOUTH NAME] ever have video game players that hook up to TV (Xbox, Wii, PSP) and handheld players (Nintendo DS, Sony PSP, iPod)in his bedroom?

₁ Yes

₂ No

₂ I don’t know

₉ Prefer not to answer

The next questions are about your relationship in general with [YOUTH NAME].

D5a. In the past 30 days, how many times have you done the following things with [YOUTH NAME]?

	1 At least once a week	2 At least once a month	3 Less Often	4 Never	5 Don’t Know	9 Prefer Not to Answer
D5_1. Gone shopping?	1	2	3	4	5	9
D5_2. Gone to a movie, sport event, concert, play, or museum?	1	2	3	4	5	9
D5_3. Watched an entire television show together?	1	2	3	4	5	9

D5b. For the following list of activities, indicate whether this is something you and [YOUTH NAME] do together at least once a week, at least once a month, less often, or never. How often do you. . .

	1 At least once a week	2 At least once a month	3 Less Often	4 Never	5 Don’t Know	9 Prefer Not to Answer
D5_1. Go to religious services or other religious activities together?	1	2	3	4	5	9
D5_2. Do homework or school projects when school is in session	1	2	3	4	5	9
D5_3. Attend a party or a family gathering together?	1	2	3	4	5	9
D5_4. Do volunteer work together to help other people or improve your neighborhood?	1	2	3	4	5	9
D5_5. Play a game or sport together?	1	2	3	4	5	9

D5c. Please tell me how often you do each of the following? How often do you…..

	1 Often	2 Some-times	3 Rarely	4 Never	5 Don’t Know	9 Prefer Not to Answer
D5c_1. make [YOUTH NAME] feel better when he is upset?	1	2	3	4	5	9
D5c_2. Tell [YOUTH NAME] when he does a good job on things.	1	2	3	4	5	9
D5c_3. Want to hear about his problems.	1	2	3	4	5	9
D5c_4. Tell [YOUTH NAME] times when he must come home.	1	2	3	4	5	9
D5c_5. Have rules that [YOUTH NAME] must follow.	1	2	3	4	5	9
D5c_6. Make sure [YOUTH NAME] doesn’t stay up too late.	1	2	3	4	5	9
D5c_7. Monitor what [YOUTH NAME] watches on TV.	1	2	3	4	5	9
D5c_8. Put restrictions on the music [YOUTH NAME] listens to or videogames he can play	1	2	3	4	5	9
D5c_9. Give [YOUTH NAME] chores around the house that he is responsible for doing.	1	2	3	4	5	9

D6. Please tell us if you strongly disagree, agree, neither agree nor disagree, agree, or strongly agree with the following statement.

I am satisfied are with the way [YOUTH NAME] and I communicate with each other.

Would you say you…

₁ Strongly Disagree

₂ Disagree

₃ Neither agree nor disagree

₄ Agree

₅ Strongly Agree

₉ Prefer not to answer

D7. How close do you feel to [YOUTH NAME]?

₁ Not at all close

₂ Not very close

₃ Somewhat close

₄ Quite close

₅ Very close

₉ Prefer not to answer

D8. Have you ever talked to [YOUTH NAME] about reasons for not using smokeless tobacco, such as dip, chewing tobacco, snuff, or snus?

₁ Yes

₂ No

₉ Prefer not to answer

D9. How are you related to [YOUTH NAME]?

1. Biological Parent

2. Step, Foster, Adoptive Parent

3. Grandparent

4. Sibling

5. Other Relative

6. Other non-relative

PROGRAMMER: LOOP SECTION D FOR EACH CHILD RESPONDENT IN THE HOUSEHOLD

E1. It is important that the interviewer does his or her job correctly. Supervisors will check the quality of the interviewer’s work and may follow-up with you by phone. Would you help by giving your telephone number?

______________

PROGRAMMER: NUMERIC 10 DIGIT STRING

Thank you for taking time to complete this survey.

OMB No: 0910-0753 Expiration Date: 10/31/2016

Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 15 minutes per response. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to PRAStaff@fda.hhs.gov.

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