Media Tracking Questionnaires 1st, 2nd and; 3rd

Attachment 4_E2b: Youth Media Tracking Instrument

Form Approved

OMB No. 0910-0753

Exp. Date 09/30/2019

Evaluation of the Public Education Campaign on Teen Tobacco-Media Tracking (ExPECTT-MT)

Subjects for Questionnaire:

Section A: Media Use and Awareness

Section B: Tobacco Use Behavior, Attitudes and Beliefs

Section C: Demographic Items

Section A: Media Use and Awareness

First, we’d like to ask you about your use of TV and other media.

A1 - A2. Thinking only about yesterday, about how much time did you spend…

	None	At least one minute, but less than 1 hour	1 hour or more, but less than 2 hours	2 hours or more, but less than 3 hours	More than 3 hours	Prefer not to answer
A2_2. Watching or uploading videos to YouTube?	1	2	3	4	5	9
A1_1. Watching TV shows on a TV, a computer or laptop, tablet, or smartphone?	1	2	3	4	5	9
A2_3. On social media such as Snapchat, Twitter, Instagram or Tumblr?	1	2	3	4	5	9
A2_4. Looking at any other type of website for anything besides schoolwork?	1	2	3	4	5	9
A2_5. Video chatting (on Snapchat, FaceTime, Googletalk, Skype, etc.)	1	2	3	4	5	9
A2_6. Text messaging?	1	2	3	4	5	9

ASK: All respondents.

F2_13. About how often do you stream video, such as Hulu, Netflix and Amazon Prime?

1. Daily

2 Almost every day

3 One or two times a week

4 Less than one time per month

5 I do not stream video

9 Prefer not to answer

ASK: All respondents.

A3. We want to ask you about some slogans or themes that might or might not have appeared in the media around here.

RANDOMIZE PRESENTATION OF A3_2b through A3_2f

A3_2b. In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme?

Digital Youth Against Tobacco (DYAT)

1 Yes

2 No

3 Not Sure

9 Prefer not to Answer

DISPLAY: DATE is three months prior to the date the participant is taking this media tracking survey.

ASK: All respondents.

A3_2c. In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme?

T he Real Cost

1 Yes

2 No

3 Not Sure

9 Prefer not to Answer

DISPLAY: DATE is three months prior to the date the participant is taking this media tracking survey.

ASK: All respondents.

A3_2e. In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme?

Tips from Former Smokers (Tips)

1 Yes

2 No

3 Not Sure

9 Prefer not to Answer

DISPLAY: DATE is three months prior to the date the participant is taking this media tracking survey.

ASK: All respondents.

A3_2f. In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme?

truth

1 Yes

2 No

3 Not Sure

9 Prefer not to Answer

DISPLAY: DATE is three months prior to the date the participant is taking this media tracking survey.

ASK: All respondents.

A3_2g. In the past 3 months, that is since [FILL DATE], have you seen or heard the following slogan or theme?

Fresh Empire

1 Yes

2 No

3 Not Sure

9 Prefer not to Answer

DISPLAY: DATE is three months prior to the date the participant is taking this media tracking survey.

ASK: All respondents.

F5_14. In the past [FILL MONTHS] months, that is since [FILL FU2_DATE TO DISPLAY FOLLOWUP 2 DATE], have you seen or heard the following slogan or theme?

Drop Vape

1 Yes

2 No

3 Not Sure

9 Prefer not to Answer

DISPLAY: DATE is three months prior to the date the participant is taking this media tracking survey.

ASK: All respondents.

A7_x. Now we would like to show you some advertisements that have been shown in the U.S. Once you have viewed the video or screenshot, please click on the forward arrow to continue with the survey.

DISPLAY: Videos or screenshots of Real Cost ads in random order.

PROGRAMMER: USE VIDEO FOR REAL COST ADS, USE SCREENSHOTS FOR TRUTH, TIPS FROM FORMER SMOKERS, AND FRESH EMPIRE ADS.

ASK: All respondents.

A8a_x. Apart from this survey, how frequently have you seen this ad in the past three months?

1 Never

2 Rarely

3 Sometimes

4 Often

5 Very often

9 Prefer not to answer

PROGRAMMER: LOOP BACK TO A7_x UNTIL ALL STIMULI OF INTEREST HAVE BEEN DISPLAYED

ASK: All respondents.

A9a. [IF A8a_x = 2 through 9 FOR ANY AD]

Where have you seen these ads? Check all that apply.

RANDOMIZE OPTIONS

1 On TV

2 Online

3 On the radio

4 In newspapers or magazines

5 Billboards or posters

6 Not sure

9 Prefer not to answer

PROGRAMMER: WE MAY ASKED ABOUT REAL COST ADS ONLY OR TRUTH AND TIPS ADS IF TIME PERMITS.

ASK: All respondents who saw an any ad rarely, sometimes, often, very often in the past three months (A8a).

A9bx. Where have you seen these ads? Check all that apply.

RANDOMIZE OPTIONS

1 At the movie theater

2 At school

3 At the mall, in an arcade or store

4 On buses, trains or other public transportation

5 Outdoors

6 Not sure

7 None of these places

9 Prefer not to answer

ASK: All respondents who saw an any ad rarely, sometimes, often, very often in the past three months (A8a).

A9cx. Where on the Internet have you seen these ads? Check all that apply.

RANDOMIZE OPTIONS

1 Online advertisements on a website

2 Social Media: Snapchat, Twitter, Instagram, Tumblr

3 Online Radio: Pandora, Spotify

4 YouTube

5 Hulu

6 Other [please specify] __________

7 I have not seen this ad Online

9 Prefer not to answer

CHECKPOINT: ASK A10 – A13 OF ALL RESPONDENTS FOR AS MANY REAL COST ADS AS TIME PERMITS (IF NOT ASKING ABOUT ALL ADS, ASK ABOUT A RANDOM SUBSET OF ADS)

ASK: All respondents who saw an any ad rarely, sometimes, often, very often in the past three months (A8a).

A10_x. How would you describe this advertisement?

A10_1.	Bad	-3	-2	-1	0	+1	+2	+3	Good
A10_2.	Unenjoyable	-3	-2	-1	0	+1	+2	+3	Enjoyable

ASK: All respondents.

A11_x. Please tell us if you strongly agree, agree, neither agree nor disagree, disagree, or strongly disagree with the following statements.

		1 Strongly Disagree	2 Disagree	3 Neither Agree or Disagree (Neutral)	4 Agree	5 Strongly Agree	9 Prefer Not to Answer
A11_1	This ad is worth Remembering	1	2	3	4	5	9
A11_2	This ad grabbed my attention	1	2	3	4	5	9
A11_3	This ad is powerful	1	2	3	4	5	9
A11_4	This ad is informative	1	2	3	4	5	9
A11_5	This ad is meaningful to me	1	2	3	4	5	9
A11_6	This ad is convincing	1	2	3	4	5	9
A11_7	This ad is terrible	1	2	3	4	5	9
A11_8	This ad is silly	1	2	3	4	5	9
A11_9	I trust the information in this ad	1	2	3	4	5	9
A11_10	This ad told me things I never knew before about tobacco	1	2	3	4	5	9
A11_12	The person/people in this ad are like me	1	2	3	4	5	9
A11_13	This ad gave me good reasons not to use tobacco	1	2	3	4	5	9
A11_14	This ad is annoying	1	2	3	4	5	9
A11_15	This ad was difficult to watch	1	2	3	4	5	9
A11_16	I can identify with what the ad says	1	2	3	4	5	9
A11_17	This ad is different from other anti-tobacco ads I’ve seen or heard	1	2	3	4	5	9
A11_18	This ad is intense	1	2	3	4	5	9

ASK: All respondents.

A12a_x. On a scale of 1 to 5, how believable do you think the information in this ad is?

1 Not believable

2

3

4

5 Believable

9 Prefer not to answer

ASK: All respondents.

A12b_x. On a scale of 1 to 5, indicate whether the ad made smoking look like something you would or wouldn’t want to do.

1 The ad makes me want to smoke

2

3

4

5 The ad makes me want to NOT smoke

9 Prefer not to answer

ASK: All respondents.

A13_x. On scale of 1 to 5, where 1 means “not at all” and 5 means “very”, please indicate how much this ad made you feel…

RANDOMIZE OPTIONS

		Not at all 1	2	3	4	Very 5
A13a_x.	Sad	1	2	3	4	5
A13b_x.	Afraid	1	2	3	4	5
A13c_x.	Irritated	1	2	3	4	5
A13d_x.	Angry	1	2	3	4	5
A13e_x.	Ashamed	1	2	3	4	5
A13f_x.	Discouraged	1	2	3	4	5
A13g_x.	Hopeful	1	2	3	4	5
A13h_x.	Motivated	1	2	3	4	5
A13i_x.	Understood	1	2	3	4	5
A13j_x.	Amused	1	2	3	4	5
A13k_x.	Worried	1	2	3	4	5
A13l_x.	Disgusted or grossed out	1	2	3	4	5
A13m_x.	Happy	1	2	3	4	5
A13n_x.	Uneasy	1	2	3	4	5
A130_x.	Surprised	1	2	3	4	5

CHECKPOINT: ASK A14 – A18 OF ALL RESPONDENTS WHO REPORT REAL COST AD AWARENESS [IF A8a_x = 2 through 9 FOR ANY REAL COST AD]

ASK: All respondents.

A14. After seeing this ad, did you look for more information online?

1 Yes

2 No

9 Prefer not to answer

ASK: Respondents who report Real Cost ad awareness [IF A8a_x = 2 through 9 FOR ANY REAL COST AD].

A15. After seeing this ad, did you visit The Real Cost website, Facebook page or Instagram?

1 Yes

2 No

9 Prefer not to answer

ASK: Respondents who report Real Cost ad awareness [IF A8a_x = 2 through 9 FOR ANY REAL COST AD].

A16. After seeing this ad, did you share The Real Cost YouTube channel with a friend?

1 Yes

2 No

9 Prefer not to answer

ASK: Respondents who report Real Cost ad awareness [IF A8a_x = 2 through 9 FOR ANY REAL COST AD].

A17. After seeing this ad, did you mention it on social media?

1 Yes

2 No

9 Prefer not to answer

ASK: Respondents who report Real Cost ad awareness [IF A8a_x = 2 through 9 FOR ANY REAL COST AD].

A18. Did you talk to anyone about this ad?

1 Yes

2 No

9 Prefer not to answer

ASK: Respondents who report Real Cost ad awareness [IF A8a_x = 2 through 9 FOR ANY REAL COST AD].

A19. [IF A18=1]

When you talked about the ads, did you talk about any of the following topics?

RANDOMIZE OPTIONS

		Yes	No	Prefer not to answer
A19_1.	This ad was good
A19_2.	This ad was not good
A19_3.	I should not smoke
A19_4.	The person I was talking to (or someone else I know) should not smoke
A19_5.	Other, specify_____________

ASK: Respondents who saw a Real Cost ad and talked to someone about the ad (A18=1).

A23. What is the main message of this ad? Check all that apply.

RANDOMIZE ORDER OF OPTIONS

1 Smoking can damage your teeth

2 Smoking can cause wrinkles

3 Cigarettes can control your life

4 The chemicals in cigarettes are harmful

5 Every cigarette costs you something

6 Nicotine can reprogram your brain (Best Answer for Hacked)

7 Cigarettes can leave you with stained teeth or gum disease (Best answer for Delivery)

8 Smoking can permanently stunt your lungs (Best answer for Straw City, but also acceptable for Little Lungs)

9 If you smoke as a teen your lungs might stay little forever (Best answer for Little Lungs, but also acceptable for Straw City)

10. [ADD KEY MESSAGE FROM REAL COST ADVERTISING]

99. I am not sure

ASK: All respondents

Section B: Tobacco Use Behavior, Attitudes & Beliefs

Cigarette Use

B1. Have you ever tried cigarette smoking, even one or two puffs?

1 Yes  GO TO B2

2 No  GO TO B7

9 Prefer not to answer  GO TO B2

ASK: All respondents

B2. [If B1 = 1 OR 9]

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

1 0 cigarettes

2 1 or more puffs but never a whole cigarette

3 1 cigarette

4 2 to 5 cigarettes

5 6 to 15 cigarettes (about 1/2 a pack total)

6 16 to 25 cigarettes (about 1 pack total)

7 26 to 99 cigarettes (more than 1 pack, but less than 5 packs)

8 100 or more cigarettes (5 or more packs)

9 Prefer not to answer

ASK: Respondents who have tried cigarette smoking or preferred not to answer if they had tried cigarette smoking (B1).

B3. [If B1 = 1 OR 9]

During the past 30 days, on how many days did you smoke cigarettes?

1 0 days  GO TO B7

2 1 or 2 days

3 3 to 5 days

4 6 to 9 days

5 10 to 19 days

6 20 to 29 days

7 All 30 days

9 Prefer not to answer

ASK: Respondents who have tried cigarette smoking or preferred not to answer if they had tried cigarette smoking (B1).

B4. [IF (B1 = 1 OR 9) AND B3 ≠1]

Do you consider yourself a smoker?

1 Yes

2 No

9 Prefer not to answer

ASK: Respondents who have tried cigarette smoking or preferred not to answer if they had tried cigarette smoking (B1), and have smoked at least one cigarette during the last 30 days (B3).

B5. [IF (B1 = 1 OR 9) AND B3 ≠1]

I plan to stop smoking cigarettes for good within the next… Please choose the first answer that fits.

1 7 days

2 30 days

3 6 months

4 1 year

5 I do not plan to stop smoking cigarettes within the next year

9 Prefer not to answer

ASK: Respondents who have tried cigarette smoking or preferred not to answer if they had tried cigarette smoking (B1), and have smoked at least one cigarette during the last 30 days (B3).

Other Tobacco Use

The next questions are about smokeless tobacco, such as dip, chewing tobacco, snuff, or snus. Common brands include [EDIT IF NECESSARY Copenhagen, Grizzly, Skoal, Camel Snus, Kodiak, and Longhorn].

B6. Have you ever used smokeless tobacco, such as chewing tobacco, snuff, snus (rhymes with goose) or dip, such as [EDIT IF NECESSARY Copenhagen, Grizzly, Skoal, Camel Snus, Kodiak, and Longhorn], even just a small amount?

1 Yes  GO TO B7

2 No  GO TO B8

9 Prefer not to answer  GO TO B7

ASK: All respondents

B7. [IF B6 = 1 or 9]

During the past 30 days, on how many days did you use chewing tobacco, snuff or dip?

1 0 days

2 1 or 2 days

3 3 to 5 days

4 6 to 9 days

5 10 to 19 days

6 20 to 29 days

7 All 30 days

9 Prefer not to answer

ASK: Respondents who have tried smokeless tobacco (B6).

The next questions are about electronic vaping products. You may also know them as electronic cigarettes, e-cigarettes, vape pens, hookah pens, e-hookahs, or personal vaporizers. Some look like cigarettes, and others look like pens, pipes, or small boxes.

B8. Have you ever tried an electronic vaping product, even one time?

1 Yes  GO TO B9

2 No

9 Prefer not to answer

ASK: All respondents

B9. [IF B8=1]

During the past 30 days, on how many days did you use an electronic vaping product?

1 0 days

2 1 or 2 days

3 3 to 5 days

4 6 to 9 days

5 10 to 19 days

6 20 to 29 days

7 All 30 days

9 Prefer not to answer

ASK: Respondents who have tried an electronic vaping product (B8).

B10. Thinking about the future…

		1 Definitely Yes	2 Probably Yes	3 Probably Not	4 Definitely Not	9 Prefer Not to Answer
B10_1	Do you think that you will try a cigarette soon?	1	2	3	4	9
B10_2	Do you think you will smoke a cigarette at any time in the next year?	1	2	3	4	9
B10_3	If one of your best friends were to offer you a cigarette, would you smoke it?	1	2	3	4	9
B10_4	Do you think that you will try smokeless tobacco such as chewing tobacco, snuff or dip soon?	1	2	3	4	9
B10_5	Do you think you will use smokeless tobacco such as chewing tobacco, snuff or dip at any time in the next year?	1	2	3	4	9
B10_6	If one of your best friends were to offer you smokeless tobacco such as chewing tobacco, snuff or dip, would you use it?	1	2	3	4	9
B10_7	Do you think that you will try an electronic vaping product soon?	1	2	3	4	9
B10_8	Do you think you will use an electronic vaping product at any time in the next year?	1	2	3	4	9
B10_9	If one of your best friends were to offer you an electronic vaping product, would you use it?	1	2	3	4	9

ASK: All respondents

B11. Smoking cigarettes is…

B11_1	Bad	-3	-2	-1	0	+1	+2	+3	Good
B11_2	Unenjoyable	-3	-2	-1	0	+1	+2	+3	Enjoyable
B11_3	Harmful	-3	-2	-1	0	+1	+2	+3	Not Harmful

ASK: All respondents

B12. Using smokeless tobacco, such as dip, chewing tobacco, snuff, or snus is…

B12_1	Bad	-3	-2	-1	0	+1	+2	+3	Good
B12_2	Unenjoyable	-3	-2	-1	0	+1	+2	+3	Enjoyable
B12_3	Harmful	-3	-2	-1	0	+1	+2	+3	Not Harmful

ASK: All respondents

B13. Smoking cigars, cigarillos, or little cigars is… (pick one)

B13_1.	Bad	-3	-2	-1	0	+1	+2	+3	Good
B13_2.	Unenjoyable	-3	-2	-1	0	+1	+2	+3	Enjoyable
B13_3.	Harmful	-3	-2	-1	0	+1	+2	+3	Not Harmful

ASK: All respondents

B14. Using electronic vaping products is… (pick one)

B14_1.	Bad	-3	-2	-1	0	+1	+2	+3	Good
B14_2.	Unenjoyable	-3	-2	-1	0	+1	+2	+3	Enjoyable
B14_3.	Harmful	-3	-2	-1	0	+1	+2	+3	Not Harmful

ASK: All respondents

B13. How much do you agree or disagree with the following statements? If I smoke I will…

		1 Strongly Disagree	2 Disagree	3 Neither Agree or Disagree (Neutral)	4 Agree	5 Strongly Agree	9 Prefer Not to Answer
B13_1.	Damage my body	1	2	3	4	5	9
B13_2.	Be controlled by smoking	1	2	3	4	5	9
B13_3.	Be unattractive	1	2	3	4	5	9
B13_4.	Inhale poisons	1	2	3	4	5	9
B13_5.	Develop cancer of the lip, mouth, tongue or throat	1	2	3	4	5	9
B13_6.	Develop sexual and/or fertility problems	1	2	3	4	5	9
B13_7.	Lose my taste buds	1	2	3	4	5	9
B13_8.	Be unable to stop when I want to	1	2	3	4	5	9
B13_9.	Get wrinkles	1	2	3	4	5	9
B13_10.	Develop skin problems	1	2	3	4	5	9
B13_11.	Have problems with my teeth	1	2	3	4	5	9
B13_12.	Lose my teeth	1	2	3	4	5	9
B13_13.	Have trouble breathing	1	2	3	4	5	9
B13_14	Shorten my life	1	2	3	4	5	9
B13_15.	Develop a smoking-related disease	1	2	3	4	5	9
B13_16.	Have bad breath	1	2	3	4	5	9
B13_17	Get sick more often	1	2	3	4	5	9
B13_18.	Decrease my sports performance	1	2	3	4	5	9
B13_19.	Waste money on cigarettes	1	2	3	4	5	9
B13_20.	Become addicted	1	2	3	4	5	9
B13_21.	Harm others with second-hand smoke	1	2	3	4	5	9
B13_22.	Be a bad influence on others	1	2	3	4	5	9
B13_22.	Miss out on things	1	2	3	4	5	9
B13_23	Stunt the growth of my lungs	1	2	3	4	5	9
B13_24	Have yellow, stained teeth	1	2	3	4	5	9
B13_25	Develop gum disease	1	2	3	4	5	9
B13_26	Have yellow, stained nails	1	2	3	4	5	9
B13_27	Change my brain	1	2	3	4	5	9
B13_28	Have little lungs	1	2	3	4	5	9

ASK: All respondents

B15. How much do you agree or disagree with the following statements about smoking cigarettes?

		1 Strongly Disagree	2 Disagree	3 Neither Agree or Disagree (Neutral)	4 Agree	5 Strongly Agree	9 Prefer Not to Answer
B15_1.	Smoking can cause immediate damage to my body.	1	2	3	4	5	9
B15_2.	It is safe for me to smoke for only a year or two, as long as I quit after that.	1	2	3	4	5	9
B15_3.	If I started to smoke occasionally I would not become addicted.	1	2	3	4	5	9
B15_4.	Smoking cigarettes helps people relieve stress.	1	2	3	4	5	9
B15_5.	Cigarette ingredients are disgusting.	1	2	3	4	5	9
B15_6.	Cigarette ingredients are dangerous.	1	2	3	4	5	9
B15_7.	Smoking is a way to show others I’m not afraid to take risks	1	2	3	4	5	9
B15_8.	Smoking cigarettes can help keep my weight down	1	2	3	4	5	9
B15_9.	Menthol cigarettes are safer than non-menthol cigarettes	1	2	3	4	5	9
B15_10.	The lungs of teenage smokers may not grow to normal size.	1	2	3	4	5	9
B15_11.	Smoking just a few cigarettes can make me crave more.	1	2	3	4	5	9
B15_12.	If I smoke, nicotine will rewire my brain.	1	2	3	4	5	9
B15_13	Smoking as a teen can permanently stunt my lungs.	1	2	3	4	5	9
B15_14	Smoking cigarettes will make me have serious breathing problems	1	2	3	4	5	9
B15_15	If I smoke, the consequences will find me.	1	2	3	4	5	9
B15_16	Nicotine can reprogram my brain	1	2	3	4	5	9
B15_17	If I smoke, it will be hard to think about anything but my next cigarette	1	2	3	4	5	9
B15_18	The nicotine in cigarettes may hack your brain	1	2	3	4	5	9
B15_19	Cigarettes may leave me with stained teeth	1	2	3	4	5	9
B15_20	Cigarettes may leave me with gum disease	1	2	3	4	5	9

ASK: All respondents

B21. How many of your four closest friends…

		0 None	1 One	2 Two	3 Three	4 Four	9 Prefer Not to Answer
B21_1.	Smoke cigarettes?	0	1	2	3	4	9

ASK: All respondents

Section C: Demographic Items

C7. Other than you, has anyone who lives with you 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 [NAME TOP BRANDS]

3 Cigars, cigarillos, or little cigars such as [NAME TOP BRANDS]

4 Tobacco out of a water pipe (also called “hookah”)

5 Electronic vaping products, such as [NAME TOP BRANDS]

6 Any other form of tobacco

7 No, no one who lives with me has used any form of tobacco during the past 30 days

9 Prefer not to answer

PROGRAMMER: PROGRAM SO THAT RESPONDENTS CAN SELECT MORE THAN ONE RESPONSE

ASK: All respondents

C8. Do you have any brother(s) and/or sister(s) who have smoked cigarettes during the past 30 days?

1 Yes

2 No

3 I don’t know

4 I don’t have any brothers or sisters

9 Prefer not to answer

ASK: All respondents

Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statements.

C9. I would like to explore strange places. 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

ASK: All respondents

C10. I like to do frightening things. 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

ASK: All respondents

C11. I like new and exciting experiences, even if I have to break the rules. 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

ASK: All respondents

C12. I prefer friends who are exciting and unpredictable. 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

ASK: All respondents

C13. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

1 ____ Number of Days

2 None

3 Don’t know

9 Prefer not to answer

PROGRAMMER: PROGRAMMER: NUMERIC RESPONSE. ALLOW A MINIMUM OF 1 AND MAXIMUM OF 30.

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED A NUMBER OUTSIDE THE ALLOWED RANGE FOR THE NUMBER OF DAYS. PLEASE ENTER A NUMBER BETWEEN 1 AND 30.” IN LOWERCASE LETTERS

RESPONDENTS CAN ONLY RESPOND WITH THE OPTION NONE, DON’T KNOW, OR TYPE IN A NUMERIC RESPONSE OF 1-30. IF RESPONDENTS TRY TO ENTER A NUMBER OF DAYS AND EITHER NONE OR DON’T KNOW, ERROR MESSAGE SHOULD SAY “YOU HAVE ENTERED A NUMBER AND SELECTED NONE OR DON’T KNOW. PLEASE ENTER A NUMBER OF DAYS, CHOOSE NONE, OR CHOOSE DON’T KNOW AS YOUR RESPONSE.”

ASK: All respondents

C14. What is your zip code?

1 ____­­____ (5 digit zip code)

2 Don’t know

9 Prefer not to answer

PROGRAMMER: NUMERIC RESPONSE. ALLOW EXACTLY 5 NUMBERS FOR VALID ZIP CODE.

IF ANYTHING ELSE IS TYPED IN, ERROR MESSAGE SHOULD SAY, “YOU HAVE ENTERED AN INVALID ZIP CODE. PLEASE ENTER A 5 DIGIT ZIP CODE.” IN LOWERCASE LETTERS

RESPONDENTS CAN ONLY RESPOND WITH THE OPTION VALID ZIP CODE OR THE OPTION DON’T KNOW. IF RESPONDENTS TRY TO DO BOTH, ERROR MESSAGE SHOULD SAY “YOU HAVE ENTERED A ZIP CODE AND SELECTED DON’T KNOW. PLEASE CHOOSE ONE OR THE OTHER AS YOUR RESPONSE.”

ASK: All respondents

C15. What county do you live in?

1 Select from drop down menu

2 Don’t know

9 Prefer not to answer

PROGRAMMER: PROGRAM SO RESPONDENTS CAN SELECT A RESPONSE FROM A DROP DOWN BOX.

DROP DOWN BOX OF COUNTY NAMES BASED ON ZIP CODE RESPONSE IN C14.

RESPONDENTS CAN ONLY RESPOND WITH THE OPTION DON’T KNOW OR SELECT AN ANSWER FROM THE DROP DOWN BOX. IF RESPONDENTS TRY TO DO BOTH, ERROR MESSAGE SHOULD SAY “YOU HAVE SELECTED A COUNTY AND DON’T KNOW. PLEASE CHOOSE ONE OR THE OTHER AS YOUR RESPONSE.”

ASK: All respondents

Thank you for taking time to complete this survey.

OMB No: 0910-0753 Expiration Date: 09/30/2019

Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 30 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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