General Population Screener and Consent Process (Youth and Parent)

Attachment 3a: Parent or Guardian Mail Screener

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

Who should complete this survey?

• An adult household member, 18 years or older, who lives at this address

• If there are multiple adults living at this address, the adult with the next birthday should complete the survey. Please do not include anyone who is away at school or away in the military or anyone who is visiting temporarily.

If you DO meet these criteria	PLEASE CONTINUE TO QUESTION 1 ON THE NEXT PAGE
If you DO NOT meet these criteria	PLEASE PASS THE SURVEY AND THE LETTER ON TO SOMEONE WHO DOES
If NO ONE in the household meets these criteria	PLEASE CHECK THE BOX BELOW AND RETURN THE SURVEY IN THE ENCLOSED ENVELOPE
	No one in the household meets these criteria	

Survey Instructions

Please use a blue or black pen to complete this survey.

There are 2 types of questions:

• For questions with a circle () please answer the question by selecting one answer and marking inside the circle like this  or like this .

• For questions with a square () please select all that apply by marking inside the square like this  or like this .

Survey Questions

1. What is your age?

 18–24

 25–34

 35–44

 45–54

 55–64

 65 or older

2. What is your sex?

 Male

 Female

3. How many adults age 18 and older live in your household, including yourself?

 1

 2

 3 or more

4. What is your current relationship status?

 Married

 Living with a partner

 Divorced

 Widowed

 Separated

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

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

 Never attended school or only kindergarten

 Elementary school (grades 1 through 8)

 High school (grades 9-12, no diploma)

 High school graduate or equivalent

 Some college (1-4 years, no degree)

 Associate’s degree (AA, AS)

 Bachelor’s degree (BA, BS, AB)

 Graduate or professional degree

6. Which of the following categories best describes the total income of your household for the past 12 months?

 Less than $10,000

 $10,000 to under $30,000

 $30,000 to under $50,000

 $50,000 to under $70,000

 $70,000 to under $110,000

 $110,000 or more

7. What is your current employment status? (Please select only one response, your main status now.)

 Working full-time as a paid employee

 Working full-time, self-employed

 Working part-time

 Not working, on a temporary layoff from a job

 Not working, looking for work

 Not working, retired

 Not working, disabled

 Not working, other

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

 Dial-up service

 DSL service

 Cable modem service

 Fiber optic service

 Mobile broadband plan for a computer or a cell phone

 Satellite internet service

 Some other service

 No internet service

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

 Private insurance coverage

 Medicare

 Medicaid or Medical Assistance

 Military, CHAMPUS, TriCare, or the VA

 Indian Health Service

 Other

 None

10. Do any of the adults (18 and older) living in the home currently smoke cigarettes?

 Yes

 No

11. Do any of the adults (18 and older) living in the home currently use dip, chewing
tobacco, snuff, or snus
such as Copenhagen, Grizzly,
Skoal, or Camel Snus,
every day, some days, rarely,
or not at all?

 Yes

 No

The next few questions ask about any children living in your home.

12. How many boys do you have living in your home?

	0	1	2	3+
Age 0-5	0	1	2	3
Age 6-10	0	1	2	3
Age 11-16	0	1	2	3
Age 17	0	1	2	3

13. How many girls do you have living in your home?

	0	1	2	3+
Age 0-5	0	1	2	3
Age 6-10	0	1	2	3
Age 11-16	0	1	2	3
Age 17	0	1	2	3

14. What is your relationship to the children in your home?

 Mother

 Father

 Grandmother

 Grandfather

 Legal Guardian

 No relation

 There are no children living in the home.

You have reached the end of the survey.

Thank you for your time.

Please return this survey to RTI in the postage-paid,
addressed envelope we have provided.

Or mail to:

RTI International

Research Operations Center

5265 Capital Boulevard

Raleigh, NC 27690-1653

Data Capture (0214131.000.002.007.002)

If you have questions, please call XXX

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 3 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.