OMB
No. 0910-0753
Exp. Date xx/xx/xxxx
Evaluation of the Public Education Campaign on Teen Tobacco- Adult (ExPECTT-A- 2nd Cohort)
Subjects
for Questionnaire:
Section
A: Home Media Environment
Section B: Environment and
Demographics
Section C: Tobacco Use and Cessation
Section D: Youth Topics
We are using a special quality control system on my laptop that will record what we say to each other to ensure I am following the correct procedures. The recording will be reviewed by RTI to monitor the quality of my work. The recordings will be deleted after my work has been reviewed and will be kept private just like all the other information you provide. You can still participate in the study even if you do not agree to this recording. The system is set up so that your child will not be recorded.
May we use this quality control recording system?
1=YES
2=NO
[If NO, then inactivate computer audio recorded interviewing for this case.]
Section A: Home Media Environment
A1. How many of the following items are there in your home? [INSERT PHOTOS]
|
0 Items |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 or more items |
99 |
A1_1. TVs? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_2. DVD or VCR players? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_3. Digital TV recorders such as TiVo or other DVR? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_4. Access to paid streaming services such as Netflix or Hulu Plus? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_5. Access to streaming video boxes like Roku or Apple TV? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_6. Access to premium channels such as HBO or Showtime? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_7. Tablet computers like an iPad, Samsung Galaxy, Motorola Xoom, or Kindle Fire? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_7a. (ASK IF A2_8 >0) How many of your (INSERT #) tablets have internet access? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_8. Other computers or laptops? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_8a. (ASK IF A2_7 >0) How many of your (INSERT #) computers or laptops have internet access? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_9. Ipods or other MP3 players, CD players, radios? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
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 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A2. 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. 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
9 Prefer not to answer
Section B: Demographics
B1. What is your age?
_______ years old
9 Prefer not to answer
B2 How many children aged 17 or younger live in your household 6 months or more of the year?
_______ Number of Children
9 Prefer not to answer
B3 Are you Hispanic, Latino/a, or of 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? Please select 1 or more of these categories.
|
1 |
B4_1. White |
1 |
B4_2. Black or African American |
1 |
B4_3. American Indian or Alaska Native |
1 |
B4_4. Asian Indian |
1 |
B4_5. Chinese |
1 |
B4_6. Filipino |
1 |
B4_7. Japanese |
1 |
B4_8. Korean |
1 |
B4_9. Vietnamese |
1 |
B4_10. Native Hawaiian |
1 |
B4_11. Guamanian or Chamorro |
1 |
B4_12. Samoan |
1 |
B4_13. Other Asian |
1 |
B4_14. Other Pacific Islander |
1 |
B9. Do you currently own or rent your home?
1 Rent
2 Own
99 Prefer not to answer
Section C: Tobacco Use and Cessation
C1. About how many cigarettes have you smoked in your entire life? Your best guess is fine.
1 1 or more puffs, but never a whole cigarette [GO TO C1a]
2 1 cigarette
3 2 to 5 cigarettes
4 6 to 15 cigarettes (about half a pack)
5 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
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
C2. About how long has it been since you last smoked cigarettes—even a puff?
|_|_| Hours [RANGE: 0–23]
|_| Days [RANGE: 0–6]
|_|_| Weeks [RANGE: 0–3]
|_|_| Months [RANGE: 0–11]
|_|_| Years [RANGE: 0–97]
1 I have never tried cigarette smoking, even one or two puffs.
9 Prefer not to answer
C3. On the average, about how many cigarettes a day do you now smoke?
Please enter the number of cigarettes below. You can use the chart below, which tells you how many cigarettes are in a pack.
¼ PACK = 5 1-1/4 PACKS = 25 2-1/4 PACKS = 45
½ PACK = 10 1-1/2 PACKS = 30 2-1/2 PACKS = 50
¾ PACK = 15 1-3/4 PACKS = 35 2-3/4 PACKS = 55
1 PACK = 20 2 PACKS = 40 3 PACKS = 60
______ Number of cigarettes
9 Prefer not to answer
C4. On the days that you smoke, how soon after you wake up do you usually have your first cigarette? Would you say…
1 Within 5 minutes
2 6–30 minutes
3 From more than 30 minutes to 1 hour
4 After more than 1 hour
9 Prefer not to answer
C5. During the past 3 months, did you stop smoking for one day or longer because you were trying to quit smoking cigarettes for good?
1 Yes
2 No
9 Prefer not to answer
The next questions are about the use of tobacco other than cigarettes.
The next questions are about e-cigarettes (e-cigs), sometimes also called vape pens, personal vaporizers and mods, e-cigars, e-pipes, e-hookahs and hookah pens.
C6. Have you ever tried any e-cigarettes, even one time?
1 Yes
2 No
9 Prefer not to answer
C7. Do you now use e-cigarettes 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. On the days that you use e-cigarettes how soon after you wake up do you usually use it? Would you say…
1 Within 5 minutes
2 6–30 minutes
3 From more than 30 minutes to 1 hour
4 After more than 1 hour
9 Prefer not to answer
C9. Do you.…
|
1 |
2 |
9 |
C9_1 Smoke cigars, cigarillos, or little cigars? |
1 |
2 |
9 |
C9_2 Use any other form of tobacco? (if yes, specify) |
1 |
2 |
9 |
C10. Among close friends, do….
1 All of them smoke?
2 Most of them smoke?
3 Most of them not smoke?
4 None of them smoke?
9 Prefer not to answer
C11. Among close relatives, do…
1 All of them smoke?
2 Most of them smoke?
3 Most of them not smoke?
4 None of them smoke?
9 Prefer not to answer
C12. Other than you, have any adults in your household used any of the following during the past 30 days…? (You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
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
6 No, no one who lives with me has used any form of tobacco during the past 30 days
9 Prefer not to answer
C13. To the best of your knowledge, has your child [YOUTH NAME] used any of the following during the past 30 days…? (You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER)
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
6 No, [YOUTH NAME] has not used any form of tobacco during the past 30 days
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
D1. Does [YOUTH NAME] have a cell phone of their own, that they generally do not share with other family members?
1 Yes
2 No
9 Prefer not to answer
(ASK D1a if D1=2 or 9)
D1a. Does [YOUTH NAME] have access to a cell phone that they share with other family members?
1 Yes
2 No
9 Prefer not to answer
(ASK D2 if D1 = 1 or 9 or D1a=1 or 9)
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/her) own
2 In a bedroom [HE/SHE] shares with someone else
2 In another room, specify______________
9 Prefer not to answer
(IF D1 = 1 or 2, AND A1_1 to A4_10 > 0, ASK CORRESPONDING FOLLOW-UP ITEM A5_1 TO A_10)
D4_1—D4_10. Does [YOUTH NAME 1] have (INSERT A1_1 to A1_10) in (his/her) 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 |
9 |
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 |
9 |
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 |
9 |
D5c_1. make [YOUTH NAME] feel better when [HE/SHE] is upset? |
1 |
2 |
3 |
4 |
5 |
9 |
D5c_2. Tell [YOUTH NAME] when [HE/SHE] does a good job on things. |
1 |
2 |
3 |
4 |
5 |
9 |
D5c_3. Want to hear about his/her problems. |
1 |
2 |
3 |
4 |
5 |
9 |
D5c_4. Tell [YOUTH NAME] times when [HE/SHE] 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/SHE] can play |
1 |
2 |
3 |
4 |
5 |
9 |
D5c_9. Give [YOUTH NAME] chores around the house that [HE/SHE] is responsible for doing. |
1 |
2 |
3 |
4 |
5 |
9 |
D6. Please tell us if you strongly agree, agree, disagree, or strongly disagree 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 (neutral)
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 smoking cigarettes or using other types of tobacco like cigars and chewing tobacco?
1 Yes
2 No
9 Prefer not to answer
Thank you for taking time to complete this survey.
OMB No: 0910-0753 Expiration Date: xx/xx/xxxx
Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 10 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
| File Type | application/msword |
| Author | PR* |
| Last Modified By | PR* |
| File Modified | 2016-06-01 |
| File Created | 2016-06-01 |