ATTACHMENT 3_E2C: PARENT/GUARDIAN BASELINE INSTRUMENT
Form Approved
OMB No. 0910-0753
Exp. Date 09/30/2019
RIHSC No. 17-XXXCTP
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
A1. How many of the following items are there in your home? [INSERT PHOTOS]
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0 Items |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 or more items |
99 Prefer not to answer |
A1_1. TVs? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
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A1_2. Digital TV recorders such as TiVo or other DVR? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
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A1_3. Tablet computers with Internet access, like an Apple iPad, Samsung Galaxy, or Kindle Fire? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
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A1_4. Desktop or laptop computers with internet access? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
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A1_9. 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 |
A1_10. Ipods or other MP3 players, CD players, radios? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_11. Smartphones or phones with internet access? |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
A1_12. Ipods or other handheld devices with internet access |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
99 |
ASK: All respondents
A2. Do you currently have access to…. [INSERT PHOTOS]
|
1 Yes |
2 No |
9 Prefer Not to Answer |
A2_1. paid streaming services such as Netflix, Amazon Video, or Hulu? |
1 |
2 |
9 |
A2_2. streaming video boxes like Google Chromecast, Apple TV, Roku, or Amazon Fire TV? |
1 |
2 |
9 |
A2_3. premium channels such as HBO, Showtime, or Starz? |
1 |
2 |
9 |
A2_4. music streaming services such as Spotify, Pandora, or Apple Music? |
1 |
2 |
9 |
ASK: All respondents
A3. 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
ASK: All respondents
A4. 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
ASK: All respondents
A5. 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
ASK: All respondents
B1. What is your age?
_______ years old
9 Prefer not to answer
ASK: All respondents
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
ASK: All respondents
B4. What race or races do you consider yourself to be? Please select 1 or more of these categories.
|
1 Yes |
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 |
ASK: All respondents
B5. What is the highest grade or level of schooling you completed?
1 8th grade or less
2 9th grade
3 10th grade
4 11th grade
5 12th grade, no diploma
6 GED or equivalent
7 High school diploma
8 Some college, no degree
9 Certificate, diploma, or associate degree: occupational, technical, or vocational program
10 Associate degree: academic program
11 Bachelor’s degree
12 Master’s degree
13 Professional school degree (examples: ND, DDS, DVM, LLB, JD)
14 Doctoral degree (examples: PhD, Edd)
99 Prefer not to answer
ASK: All respondents
The next question is about the total income of YOUR HOUSEHOLD for the PAST 12 MONTHS. 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).
B6. Thinking about members of your family living in this household, what is your combined annual income, meaning the total pre-tax income from all sources earned in the past year?
1 $0 to $9,999
2 $10,000 to $14,999
3 $15,000 to $19,999
4 $20,000 to $34,999
5 $35,000 to $49,999
6 $50,000 to $74,999
7 $75,000 to $99,999
8 $100,000 to $199,999
9 $200,000 or more
99 Prefer not to answer
ASK: All respondents
B7. Are you now …?
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
9 Prefer not to answer
ASK: All respondents
B8. Which statement best describes your current employment status?
1 Working full time as a paid employee
2 Working full time, self-employed
3 Not working, on temporary layoff from a job
4 Not working, looking for work
5 Not working, retired
6 Not working, disabled
7 Not working, other
9 Prefer not to answer
ASK: All respondents
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
ASK: All respondents
C1a. Do you now smoke cigarettes 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
ASK: All respondents
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
ASK: All respondents who respond “I do not smoke at all,” to C1a.
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
ASK: All respondents who respond “I smoke every day,” or “I smoke some days,” to C1a.
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
ASK: All respondents who respond “I smoke every day,” or “I smoke some days,” to C1a.
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
ASK: All respondents who respond “I smoke every day,” or “I smoke some days,” to C1a.
The next questions are about the use of tobacco other than cigarettes.
C1a. Do you now smoke cigars, cigarillos, or little cigars 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
ASK: All respondents
C1a. Do you now smoke hookah 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
ASK: All respondents
C1a. Do you now smoke smokeless tobacco, such as chewing tobacco, snuff, or dip 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
ASK: All respondents
C10. Among close friends, do….
1 All of them smoke cigarettes?
2 Most of them smoke cigarettes?
3 Some of them not smoke cigarettes?
4 None of them smoke cigarettes?
9 Prefer not to answer
ASK: All respondents
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 [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 or electronic cigarettes, 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
ASK: All respondents
C14. For tobacco products that are burned, such as cigarettes, cigars, pipes or hookah, 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
5 Prefer not to answer
ASK: All respondents
[REPEAT FOR EACH ELIGIBLE YOUTH]
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 [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 or electronic cigarettes, such as [NAME TOP BRANDS]
6 any other form of tobacco
7 No, [YOUTH NAME] has not used any form of tobacco during the past 30 days
9 Prefer not to answer
ASK: All respondents
D1. Does [YOUTH NAME] have [his/her] own smartphone, or a cell phone with internet access?
1 Yes
2 No
3 I don’t know
9 Prefer not to answer
ASK: All respondents
(ASK if A1 = 1 or 2)
D2. Does [YOUTH NAME] share or use a smartphone or cell phone that belongs to someone else in your home?
1 Yes
2 No
3 I don’t know
9 Prefer not to answer
ASK: All respondents who respond “yes,” to D1.
The next questions are about your relationship in general with [YOUTH NAME].
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/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 |
ASK: All respondents
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
ASK: All respondents
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
ASK: All respondents
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
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 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 | Pamela Rao |
| Last Modified By | SYSTEM |
| File Modified | 2017-11-02 |
| File Created | 2017-11-02 |