Parent Of Youth Baseline Survey Participants

ATTACHMENT 12_R: FIELD INTERVIEWER VERIFICATION

Form Approved

OMB No. 0910-0753

Exp. Date 09/30/2019

ID:

Hello, my name is _______________________, with RTI International. May I speak with [ADULT 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 SPREADSHEET.)

IF AVAILABLE - (IF SPEAKING TO THE SAME PERSON CONTINUE IF NOT REINTRODUCE YOURSELF) I am calling to verify the work of one of our field representatives, [REPRESENTATIVE NAME], who reported conducting an interview with a you on [DATE OF INTERVIEW] for the FDA Health and Media Study. Do you remember completing the interview?

YES  GO TO QUESTION 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. IF RESPONDENT STILL DOES NOT REMEMBER CONFIRM THAT YOU HAVE THE CORRECT ADDRESS AND DIALED THE CORRECT PHONE NUMBER. IF ADDRESS AND PHONE NUMBER ARE CORRECT, SKIP TO CONCLUSION.

2. So I can confirm our interviewer went to the correct home, could you verify your address?

3. Did an interviewer call your household to set up an appointment for an interview?

1 = YES

2 = NO  PROBE ____________________________________________________

4. Was your child’s interview conducted in your home or somewhere else?

1 = IN RESPONDENT’S HOME

2 = SOMEWHERE ELSE (SPECIFY) ________________________________________

5. 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

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

1 = YES

2 = NO  PROBE FOR SPECIFIC INFORMATION

NOTE: YOU CAN PICK ONE CHILD. USUALLY THE PARENT WILL TELL YOU IF MORE THAN ONE WAS INTERVIEWED.

7. Were you given a printed copy of the consent form to follow as the interviewer read it to you?

1 = YES

2 = NO

8. Was this your child’s first interview for the FDA Health and Media Study?

1 = YES  PROBE . THIS SHOULD BE THEIR 2^ND OR 3^RD INTERVIEW

9. Did an interviewer come to your home between May and August of this year to interview your child about tobacco?

1 = YES

2 = NO  PROBE

10. Did your child enter answers into the laptop himself?

1 = YES

2 = NO  PROBE

11. About how long did it take your child to complete the interview?

1 = <30 MINUTES

2 = 30-44 MINUTES

3 = 45-59 MINUTES

4 = 60-90 MINUTES

5 = OVER 90 MINUTES

12. We also conducted the survey online. Were you aware of this option?

1 = YES

2 = NO

13. Was your child given money as a thank you for completing the survey?

1 = YES

2 = NO  PROBE IF NO SKIP TO Q16

14. How much did he receive?

$ _______________

IF RESPONDENT STATES DOESN’T REMEMBER OR A DIFFERENT AMOUNT OTHER THAN $20 PROBE: Did you receive one bill or two bills?

15. In what form were you paid? (For example: cash, check, money order.)

________________

16. Did the interviewer behave in a professional manner?

1 = YES

2 = NO (EXPLAIN) __________________________________________________

17. 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

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.