Parent Of Youth Baseline Survey Participants

Attachment 12_E2: Telephone Verification Survey

Form Approved

OMB No. 0910-0753

Exp. Date 09/30/2019

RIHSC No. 17-XXXCTP

Telephone Verification Survey for the Evaluation of the Public Education Campaign on Teen Tobacco (ExPECTT)

Parent and Youth Verifications

ID:

1. Hello, my name is _______________________, with RTI International. May I speak with (RESPONDENT)?

IF UNAVAILABLE - When would be a better time to speak with (RESPONDENT) or can (he/she) be reached at another number? (RECORD INFORMATION IN RECORD OF CALLS.)

IF AVAILABLE - I am calling to verify the work of one of our field representatives, (REPRESENTATIVE NAME), who reported conducting an interview with you on (DATE OF INTERVIEW) for the Evaluation of the Public Education Campaign on Teen Tobacco. Do you remember completing the interview?

1 = YES

2 = NO  IF RESPONDENT DOES NOT REMEMBER THE INTERVIEW, REMIND HIM/HER THAT THE FI ASKED QUESTIONS ABOUT HOUSEHOLD CHARACTERISTICS, MEDIA USE, ATTITUDES TOWARDS TOBACCO. [FILL CHILD NAME]. IF RESPONDENT STILL DOES NOT REMEMBER, SKIP TO CONCLUSION.

2. First, were you interviewed in person?

1 = YES

2 = NO

ASK: All respondents

3. About how long was the interviewer present in your home?

1 = <30 MINUTES

2 = 30-44 MINUTES

3 = 45-59 MINUTES

4 = 60-90 MINUTES

5 = OVER 90 MINUTES

ASK: All respondents

4. Was the interview conducted in your home or somewhere else?

1 = IN RESPONDENT’S HOME

2 = SOMEWHERE ELSE (SPECIFY) ________________________________________

ASK: All respondents

5. Was your child paid for their participation in the study?

1 = YES

2 = NO  SKIP TO Q8

ASK: All respondents

[IF 5=1]

6. How much did they receive?

$ _______________

ASK: Respondents who report their child was paid for survey participation (item 5)

[IF 5=1]

7. In what form were you paid? [EXAMPLES: CASH, CHECK, MONEY ORDER]

________________

ASK: Respondents who report their child was paid for survey participation (item 5)

8. Was your child, [FILL CHILD], interviewed?

1 = YES

2 = NO  SKIP TO Q23

ASK: All respondents

[IF 8=2]

9. Did your child enter some of the answers into the computer themselves?

1 = YES

2 = NO

ASK: Respondents who report that their child was not interviewed (item 8)

10. Did the interviewer behave in a professional manner?

1 = YES

2 = NO (EXPLAIN) __________________________________________________

ASK: All respondents

11. Did [FILL CHILD]’s interview take place on the same day as your interview or on a different day?

1 = SAME DAY

2 = DIFFERENT DAY

ASK: All respondents

12. About how long did [FILL CHILD] interview take?

1 = <30 MINUTES

2 = 30-44 MINUTES

3 = 45-59 MINUTES

4 = 60-90 MINUTES

5 = OVER 90 MINUTES

ASK: All respondents

13. Those are all the questions I have. Do you have any additional comments you’d like to make about the interview(s)?

1 = YES (SPECIFY) ______________________________________________________

2 = NO

ASK: All respondents

CONCLUSION: Thank you very much for your time. Have a nice day/evening.

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 2 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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