General Population Screener and Consent Process (Youth and Parent)

Attachment 3_E2A: PARENT/GUARDIAN TABLET SCREENER (ExPECTT)

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-2^nd Cohort)

Subjects for Questionnaire:

Study Screener

Parent or Guardian Screener

SCR1.

[IF NO TELEFORM SCREENER WAS COMPLETED]

Hello, my name is [FI NAME] with RTI International in North Carolina. We are conducting a national study sponsored by the U.S. Food and Drug Administration.

You should have received a letter explaining the study.

HAND R COPY OF LETTER EXPLAINING THE STUDY.

[IF TELEFORM MAIL SCREENER WAS COMPLETED]

Hello, my name is [FI NAME] with RTI International in North Carolina. We are conducting a national study sponsored by the U.S. Food and Drug Administration. Thank you for mailing us back the survey that determined your eligibility for the health study. Based on your responses you were flagged to be eligible for the study. We are here today to verify a few information and to conduct the study.

You should have received a letter explaining the study.

HAND R COPY OF LETTER EXPLAINING THE STUDY.

NEXT [GO TO SCR2]

ASK: All respondents

SCR2.

First, let me verify: do you live here?

1 YES GO TO SCR3

2 NO GO TO SCR3a

9 DK/ REF GO TO SCR3a

ASK: All respondents

SCR3. [IF SCR2=YES]

IF NECESSARY (Are you 18 or older?)

1 YES

2 NO GO TO SCR3a

9 DK/REF GO TO SCR3a

ASK: Respondents for which it is not clear that they are age 18 or older

PROGRAMMER: IF SCR3a=1 GO TO SCR4, ELSE GO SCR3a.

SCR3a. [IF (SCR2=2 OR SCR2=DK/REF ) OR (SCR3=2 OR SCR3=DK/REF)]

I need to speak with someone who is 18 or older and lives here. May I speak with someone who can help me?

1 YES, PERSON IS AVAILABLE GO TO SCR1

2 YES, BUT NEED TO SCHEDULE GO TO SCR27a-b

3 NO, NO ONE LIVING HERE 18 OR OLDER GO TO SCR29a-b

9 DK/ REF GO TO SCR29a-b

ASK: Respondents who do not or may not live in the house, or for which it is not clear that they are age 18 or older

PROGRAMMER: IF SCR3a=1 THEN GO BACK TO SCR1. IF SCR3a=2 GO TO SCR27a-b. IF SCR3a=3 GO TO SCR29a-b. IF SCR3a=9 GO TO SCR29a-b.

SCR4.

Next, I need to verify – is this

STREET: (NUMBER AND STREET)

CITY: (CITY)

STATE: (STATE)

ZIP: (ZIP)

1 ADDRESS IS CORRECT GO TO SCR5

3 FI AT WRONG ADDRESSBREAKOFF: SELECT CORRECT CASE

ASK: All respondents

SCR5.

STUDY DESCRIPTION

GIVE PERSON STUDY DESCRIPTION AND SAY

I’d like you to follow along with me as I read the following statement. It describes the survey and assures the privacy to the fullest extent allowable by law of any information you provide. It also explains that your answers are used for statistical purposes only and that your participation is voluntary.

STUDY DESCRIPTION TEXT

Your address is one of several in this area randomly chosen for the U.S. Food and Drug Administration (FDA) Health and Media study. This study, sponsored by the FDA, is collecting information from boys across the United States about their attitudes related to health, health behaviors, and advertisements they may have seen on TV and/or online.

You cannot be identified by any of the information you give to us. Your name and address will never be connected to your answers. Also, federal law requires that we keep all of your responses private to the fullest extent allowable by law. Any data you provide will only be used for statistical purposes and reported in aggregate form.

The screening questions take just a few minutes to determine if anyone in your household is eligible. One or possibly more children in your household may be asked to voluntarily participate in the survey. If anyone is chosen, the interview itself will take approximately 30-40 minutes. We would also like to ask you a few questions about your household’s characteristics and media use. You and your child can refuse to answer any questions, and you can quit at any time. Your child will be offered $20 upon completing the interview.

We will conduct three follow-up surveys every eight months to understand changes in health-related attitudes and behaviors over time. Each of these additional interviews will also be completely voluntary. If your child participates in future rounds, he or she will be offered a [INCENTIVE AMOUNT] incentive for participating in each of the three in-person interviews.

[FILL IF CAPI RESPONDENT: 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.

May we use this quality control recording system? 

1=YES

2=NO

IF NO, DEACTIVATE AUDIO RECORDED INTERVIEWING FOR THIS SCREENER CASE]

If you have any questions about the study, please contact the project representative [ADD NAME], at [ADD NUMBER] extension [ADD EXTENSION]. If you have questions about your rights as a study participant, call toll-free: RTI’s Office of Human Research Protections at 1-866-214-2043.

Thank you for your cooperation and time.

ASK: All respondents

PROGRAMMER: IF TELEFORM MAIL SCREENER COMPLETED, GO TO SCR6. IF TELEFORM NOT COMPLETED, GO TO SCR7.

SCR6. [IF TELEFORM MAIL SCREENER COMPLETED]

In the mail questionnaire that your household returned, it was reported that there are youth aged 11-16. Is this correct?

1 YES SEE PROGRAMMING INSTRUCTIONS

2 NO GO TO SCR17

9 DK/REF GO TO SCR17

ASK: Respondents who returned the mail screener

PROGRAMMER: IF SCR6=2 OR 9, GO TO SCR17.

IF SCR6=1 LET CALC_ELIG=GO TOTEL_NUMELIG_YOUTH AND GO TO SCR20.

GO TOGO TO

SCR7. [IF TELEFORM MAIL SCREENER NOT COMPLETED]

Including yourself, how many adults age 18 and older usually live in this household?

_____ [RANGE 1-20]

9 DK/REF

ASK: All respondents who did not return the mail screener. Respondents who do not confirm that the number of youth in the household matches the number reported on the mail screener.

PROGRAMMER: IF SCR7 = 1, GO TO SCR7_CONFIRM. IF SCR7>1, GO TO SCR8.

SCR7_CONFRM

Is there only one adult in this household?

1 YES

2 NO

9 DK/REF

ASK: Respondents who report only one adult in the household in SCR7.

PROGRAMMER: IF SCR7_CONFRM = 1, GO TO SCR8. IF SCR7_CONFRM = 2, GO BACK TO SCR7 TO CORRECT

SCR8. Which best describes this home?

1. A trailer or mobile home

2. A one-family house detached from any other house

3. A one-family house attached to one or more houses

4. Apartment in a building with 2 units

5. Apartment in a building with 3 to 9 units

6. Apartment in a building with 10 to 49 units

7. Apartment in a building with 50 or more units

8. Something else

9. DK/REF

ASK: All respondents

SCR9. Is this home –

1. Owned by you or someone in your household

2. Rented

3. Occupied without payment of rent

9. DK/REF

ASK: All respondents

SCR 10. Which of the following languages are spoken in this home? (MARK ALL THAT APPLY)

1. English

2. Spanish

3. Other language(s)

9. DK/REF

ASK: All respondents

SCR11. Including you, how many of the [FILL RESPONSE TO SCR7] adults (18 years or older) living in this home are male, and how many are female?

SCR11a. How many are male?

_____ [RANGE 0-20]

9 DK/REF

SCR11b. How many are female?

_____ [RANGE 0-20]

9 DK/REF

ASK: All respondents

SCR12. Including you, how many of the [FILL RESPONSE TO SCR7] adults (18 years or older) living in this home are in each of the following age groups?

SCR12a. How many are age 18-24?

_____ [RANGE 0-20]

9 DK/REF

SCR12b. How many are age 25-34?

_____ [RANGE 0-20]

9 DK/REF

SCR12c. How many are age 35-44?

_____ [RANGE 0-20]

9 DK/REF

SCR12d. How many are age 45-54?

_____ [RANGE 0-20]

9 DK/REF

SCR12e. How many are age 55-64?

_____ [RANGE 0-20]

9 DK/REF

SCR12f. How many are age 65+?

_____ [RANGE 0-20]

9 DK/REF

ASK: All respondents

SCR13. Including you, how many of the [FILL RESPONSE TO SCR7] adults (18 years or older) living in this home…

SCR13d. Have an Associates, Bachelor’s, graduate or professional degree

_____ [RANGE 0-20]

9 DK/REF

SCR13c. Attended some college but do not have a degree

_____ [RANGE 0-20]

9 DK/REF

SCR13b. Have a HS diploma/GED but did not attend college

_____ [RANGE 0-20]

9 DK/REF

SCR13a. Do not have a HS diploma or equivalent (GED)

_____ [RANGE 0-20]

9 DK/REF

ASK: All respondents

SCR14. Including you, how many of the [FILL RESPONSE TO SCR7] adults (18 years or older) living or staying in this home are…

SCR14a. How many are Hispanic or Latino?

_____ [RANGE 0-20]

9 DK/REF

ASK: All respondents

SCR34. Including you, how many of the [FILL RESPONSE TO SCR7] adults (18 years or older) living or staying in this home are…

SCR34b. How many are White?

_____ [RANGE 0-20]

9 DK/REF

SCR34c. How many are Black or African-American?

_____ [RANGE 0-20]

9 DK/REF

SCR34d. How many are Asian?

_____ [RANGE 0-20]

9 DK/REF

SCR34e. How many are some other race or ethnicity?

_____ [RANGE 0-20]

9 DK/REF

ASK: All respondents

SCR33. Do you or any member of this household have access to the Internet using a… (select all that apply)

SCR15a. Cellular data plan for a smartphone or other mobile device?

○ Yes

○ No

SCR15b. Broadband (high speed) Internet service such as cable, fiber optic, or DSL service installed in this household?

○ Yes

○ No

SCR15c. Satellite Internet service installed in this household?

○ Yes

○ No

SCR15d. Dial-up Internet service installed in this household?

○ Yes

○ No

SCR15e. Some other service?

○ Yes (describe)_________________________

○ No

ASK: All respondents

SCR34. IN THE PAST 12 MONTHS, did you or any member of this household receive benefits from the Food Stamp Program or SNAP (the Supplemental Nutrition Assistance Program)? Do NOT include WIC, the School Lunch Program, or assistance from food banks.

○ Yes

○ No

ASK: All respondents

SCR15. The next question is about cigarette smoking.

Including you, how many of the [FILL RESPONSE TO SCR7] adults (18 years or older) living in this home…

SCR15a. Smoke cigarettes every day or some days?

_____ [RANGE 0-20]

9 DK/REF

ASK: All respondents

SCR17.

How many youth ages 0 to 17 live here now?

_____ [RANGE 0-9]

9 DK/REF

ASK: All respondents

PROGRAMMER:

IF SCR17=0, GO TO SCR18

IF SCR17 = DK/ REF GO TO SCR18

IF SCR17 = 1 or >1, GO TO SCR19

SCR18.

I’m sorry but I’m unable to determine whether anyone in your household is eligible. Is there someone else who lives in this household that I can speak with?

1 YES

2 YES, BUT NEED TO SCHEDULE

3 NO

9 DK/REF

ASK: If SCR17= DK/ REF

PROGRAMMER:

IF SCR18 = 1 GO BACK TO SCR1.

IF SCR18 = 2 THEN GO TO SCR27a-b.

IF SCR18 = 3 OR SCR18=DK/REF, GO TO SCR28.

SCR19. How many children (17 years or younger) living in this home are in each of the following age groups?

SCR19a. How many are age 0-5?

_____ [RANGE 0-20]

9 DK/REF

SCR19b. How many are age 6-10?

_____ [RANGE 0-20]

9 DK/REF

SCR19c. How many are age 11-16?

_____ [RANGE 0-20]

9 DK/REF

SCR19d. How many are age 17?

_____ [RANGE 0-20]

9 DK/REF

ASK: All respondents

PROGRAMMER:

LET CALC_ELIG= SCR19c

IF CALC_ELIG=0, GO TO SCR29a-b.

IF CALC_ELIG=1, GO TO SCR20.

IF CALC_ELIG>1, GO TO SCR20.

SCR20. [ASK IF SCR19c > 0: IN OTHER WORDS, IF THERE ARE YOUTH AGES 11-16]

YOUTH ROSTER INTRO: ONE YOUTH

[IF CALC_ELIG=1]

“Please tell me the first name, nickname, or initials of the child between the ages of 11 and 16. We ask for the name to help you keep track of household members as you answer the questions and it will not be recorded by the study.”

YOUTH ROSTER INTRO:9MULTIPLE YOUTH

[IF CALC_ELIG>1 AND CALC_ELIG <10]

“We would like to know about the children ages 11-16 living in your household, starting with the oldest and ending with the youngest.”

“Please tell me the first name, nickname, or initials of the oldest child between the ages of 11 and 16. We ask for the name to help you keep track of household members as you answer the questions and it will not be recorded by the study.”

[IF CALC_ELIG >10]

”We are only going to ask you about the oldest 9 children who are ages 11-16 living in your household. We will start with the oldest and end with the youngest.”

“Please tell me the first name, nickname, or initials of the oldest child between the ages of 11 and 16. We ask for the name to help you keep track of household members as you answer the questions and it will not be recorded by the study.”

SCR20_1. [YOUTH NAME #1] ____________________

SCR20_2. [YOUTH NAME #2] ____________________

SCR20_3. [YOUTH NAME #3] ____________________

SCR20_4. [YOUTH NAME #4] ____________________

SCR20_5. [YOUTH NAME #5] ____________________

SCR20_6. [YOUTH NAME #6] ____________________

SCR20_7. [YOUTH NAME #7] ____________________

SCR20_8. [YOUTH NAME #8] ____________________

SCR20_9. [YOUTH NAME #9] ____________________

ASK: All respondents who report a child in the household between the ages of 11 and 16 in SCR19c.

PROGRAMMER: Loop SCR20 as many times as SCR19c (i.e., the number of youths ages 11-16 living in household) with a max of 9 times.

INTERVIEWER IF NEEDED: (We ask for the name to help you keep track of household members as you answer the questions and it will not be recorded by the study.)

PROGRAMMER: WHEN NAMING VARIABLES, MAKE SURE THAT _n REFLECTS THE NUMBER OF ITERATION.

FOR EXAMPLE, THE SIXTH ITERATION IS SCR20_6, SCR21_6, AND SCR22_6.

The NINTH ITERATION IS SCR20_9, SCR21_9, AND SCR22_9.

LET NAME_ELIG_n= NAME OF CHILD [SCR20_n]

CALCULATE THE FOLLOWING:

CALC_ELIG= NUMBER OF CHILDREN FROM SCR19c

SCR20a. [ASK IF CALC_ELIG=1]

ONE ELIGIBLE YOUTH

“Thank you. It turns out that [NAME_ELIG] is eligible for the survey. To proceed, I need to speak with the parent or legal guardian of [NAME_ELIG].”

What is the first name, nickname, or initials of the parent or legal guardian of [NAME_ELIG]? Again, we ask for the name to help keep track of household members as you answer the questions and it will not be recorded by the study.”

__________ [ALLOW 20 CHARACTERS]

DK/REF

PROGRAMMER:

IF SCR20a = DK/REF, SOFT PROMPT: “Please let us know the first name, nickname, or initials of the parent or legal guardian of [NAME_ELIG]. We only ask this to help keep track of household members as we go through the questions. All information collected as part of the study will be kept private to the fullest extent allowable by law, and nothing you tell us will be reported with your name.”

IF SCR20a= DK/ REF the second time, GO TO SCR20c.

ASK: All respondents who report one child in the household between the ages of 11 and 16 in SCR19c.

SCR20b.

Would that be you?

1 YES

2 NO

9 DK/REF

GO TO.

GO TO.

ASK: All respondents who report one child in the household between the ages of 11 and 16 in SCR19c.

PROGRAMMER: IF SCR20b = 1, GO TO SCR24. IF SCR20b = 2, GO TO SCR20c

SCR20c.

Can I talk to the parent or legal guardian of [NAME_ELIG]?

1. YES, CURRENT RESPONDENT IS THE PARENT OR LEGAL GUARDIAN

2. YES, DIFFERENT ADULT CAME FORWARD

3 NOT NOW, BUT LATER

4 NO, REFUSAL TO INTERVIEW

ASK: All respondents who report one child in the household between the ages of 11 and 16 in SCR18c.

PROGRAMMER: IF SCR20c=1, GO TO SCR24. IF SCR20c=2, GO TO SCR26. IF SCR20c = 3, GO TO SCR127. IF SCR20c=4, GO TO SCR28.

SCR21a. [ASK IF CALC_ELIG>1]

MULTIPLE ELIGIBLE YOUTH

“Thank you. It turns out that you have children who are eligible for the survey. To proceed, I need to speak with the parent or legal guardian of the children.”

INTERVIEWER: WAIT FOR ONE PARENT OR LEGAL GUARDIAN TO COME FORWARD.

SCR21b.

Do the children have the same parent or legal guardian?

1 YES

2 NO

9 DK/ REF

GO TO

GO TO

ASK: All respondents who report multiple children in the household between the ages of 11 and 16 in SCR19c.

PROGRAMMER: IF SCR21b = 1, GO TO SCR21c. IF SCR21b = 2 OR SCR21b=DK/REF, GO TO SCR22.

SCR21c. [ASK IF SCR21b=1]

What is the first name, nickname, or initials of the parent and legal guardian of the children? Again, we ask for the name to help keep track of household members as you answer the questions and it will not be recorded by the study.

__________ [ALLOW 20 CHARACTERS]

DK/REF

ASK: All respondents who report all the children in the household between the ages of 11 and 16 in SCR19c have one parent or legal guardian.

PROGRAMMER:

IF SCR21c = DK/REF, SOFT PROMPT: “Please let us know the first name, nickname, or initials of the parent or legal guardian of the children. We only ask this to help keep track of household members as we go through the questions. All information collected as part of the study will be kept private to the fullest extent allowable by law, and nothing you tell us will be reported with your name.”

IF SCR121c= DK/ REF the second time, GO TO SCR21d.

SCR21d.

Would that be you?

1 YES

2 NO

9 DK/REF

ASK: All respondents who report all the children in the household between the ages of 11 and 16 in SCR19c have one parent or legal guardian.

PROGRAMMER: IF SCR121d = 1, GO TO SCR24. IF SCR10c = 2, GO TO SCR21e.

GO TO

SCR21e.

Can I talk to the parent or legal guardian of the children?

1. YES, CURRENT RESPONDENT IS THE PARENT OR LEGAL GUARDIAN

2. YES, DIFFERENT ADULT CAME FORWARD

3 NOT NOW, BUT LATER

4 NO, REFUSAL TO INTERVIEW

ASK: All respondents who report they are not the parent or legal guardian of all the children in the household between the ages of 11 and 16.

PROGRAMMER: IF SCR21e=1, GO TO SCR24. IF SCR21e=2, GO TO SCR26. IF SCR21e = 3, GO TO SCR27a-b. IF SCR21e=4, GO TO SCR28.

SCR22. [ASK IF SCR20e=2]

[PROGRAMMER: START WITH NAME_ELIG_1, NAME_ELIG_2, AND SO ON.]

Please tell me the first name, nickname, or initials of the parent or legal guardian of the following children. Again, we ask for the name to help keep track of household members as you answer the questions and it will not be recorded by the study.

SCR22_1	[NAME_ELIG_1]	[ALLOW 20 CHARACTERS]	DK/REF
SCR22_2	[NAME_ELIG_2]	[ALLOW 20 CHARACTERS]	DK/REF
SCR22_3	[NAME_ELIG_3]	[ALLOW 20 CHARACTERS]	DK/REF
SCR22_4	[NAME_ELIG_4]	[ALLOW 20 CHARACTERS]	DK/REF
SCR22_5	[NAME_ELIG_5]	[ALLOW 20 CHARACTERS]	DK/REF
SCR22_6	[NAME_ELIG_6]	[ALLOW 20 CHARACTERS]	DK/REF
SCR22_7	[NAME_ELIG_7]	[ALLOW 20 CHARACTERS]	DK/REF
SCR22_8	[NAME_ELIG_8]	[ALLOW 20 CHARACTERS]	DK/REF
SCR22_9	[NAME_ELIG_9]	[ALLOW 20 CHARACTERS]	DK/REF

PROGRAMMER: populate the table UNTIL CALC_ELIG. so, IF CALC_ELIG=4, table will have name_elig_1 (and scr22_1) to name_elig_4 (SCR22_4).

LET i=1 TO CALC_ELIG.

IF SCR22_i = DK/REF,

SOFT PROMPT: “Please let us know the first name, nickname, or initials of the parent or legal guardian of [NAME_ELIG_i]. We only ask this to help keep track of household members as we go through the questions. All information collected as part of the study will be kept private to the fullest extent allowable by law, and nothing you tell us will be reported with your name.”

IF SCR22_i= DK/ REF THE SECOND TIME, GO TO SCR23a_i.

IF SCR22_i NE DK/REF, GO TO SCR23b_i

PROGRAMMER: IF SCR22_i=DK/ REF SECOND TIME, ASK SCR23a_i.

SCR23a_i.

Can I talk to the parent or legal guardian of [NAME_ELIG_i]?

1. YES, CURRENT RESPONDENT IS THE PARENT OR LEGAL GUARDIAN

2. YES, DIFFERENT ADULT CAME FORWARD

3 NOT NOW, BUT LATER

4 NO, REFUSAL TO INTERVIEW

ASK: All respondents who answer DK/REF when indicating the name of the parent or legal guardian for any of the eligible youth.

PROGRAMMER: IF SCR23a_i=1, GO TO SCR24. IF SCR23a_i =2, GO TO SCR26. IF SCR23a_i = 3, GO TO SCR27a-b. IF SCR23a_i =4, GO TO SCR28.

IF SCR22_i NE DK/ REF, ASK SCR23b_i.

SCR23b_i.

May I speak with [SCR22_i]?

1. YES, CURRENT RESPONDENT IS [SCR22_i]

2. YES, DIFFERENT ADULT CAME FORWARD

3 NOT NOW, BUT LATER

4 NO, REFUSAL TO INTERVIEW

DK/ REF

ASK: All respondents who do not answer DK/REF when indicating the name of the parent or legal guardian for any of the eligible youth.

PROGRAMMER: IF SCR23b_i=1, GO TO SCR24. IF SCR23b_i =2, GO TO SCR26. IF SCR23b_i = 3, GO TO SCR27a-b. IF SCR23b_i =4, GO TO SC286.

SCR24. [IF SC20b =1 OR SC20c=1 OR SCR212 = 1 OR SCR21e=1, OR SCR23a_i=1 OR SCR23b_i=1]

I’d like to explain more about this study and how you may be able to help us. If this is a good time, we could get started now. I will need a place to set up a laptop computer.

1 YES

2 NONE OF THE CHILDREN ARE AVAILABLE BUT PARENT/ LEGAL GUARDIAN IS AVAILABLE

3 CHILDREN AND PARENT/LEGAL GUARDIAN NOT AVAILABLE NOW, BUT LATER

4 NO, REFUSAL TO INTERVIEW

ASK: All respondents who have been identified as the parent or legal guardian of eligible youth in the household.

PROGRAMMER: IF SCR24=1 OR SCR24= 2 GO TO SCR24a, READY-FOR-CONSENT. IF SCR24=3 GO TO SCR27a-b. IF SCR24=4, GO TO SCR28.

SCR24a. [ASK IF SCR24=1 OR SCR26 = 1]

[PROGRAMMER:

IF (SCR24=1 OR SCR26=1), FILL_SCR24a_1= “begin”

IF (SCR24 =2 OR SCR26=2), FILL_SCR24a_1= “continue on with the parent interview”

IF (SCR24=3 OR SCR26=3), FILL_SCR24a_1= “end”

Let i=CALC_ELIG.

IF CALC_ELIG=1 AND ((SCR24=1 OR SCR26=1) OR (SCR24=3 OR SCR26=3)), FILL_SCR24a_2= [NAME_ELIG],

IF CALC_ELIG>1 AND ((SCR24=1 OR SCR26=1) OR (SCR24 =3 OR SCR26 =3)), FILL_SCR24a_2=”the eligible children”

IF CALC_ELIG>1 AND IF (SCR24=2 OR SCR26 =2), FILL_SCR24a_2= “for us to come back and interview the child(ren)”FILL_SCR12a_2=[NAME_ELIG_i]

Before we [FILL_SCR24a_1], we need your permission for [FILL_SCR24a_2] to take the survey. All eligible youths who completes the survey will receive $20 in cash as a token of our appreciation.

INTERVIEWER: GIVE PARENT OR LEGAL GUARDIAN THE PARENT CONSENT AND PARENTPERMISSION FORMS.

DID PARENT OR LEGAL GUARDIAN CONSENT?

1 YES

2 NO

ASK: All respondents who have been identified as the parent or legal guardian of eligible youth in the household and are available now.

PROGRAMMER:

IF (SCR24=1 AND SCR24a=1) OR (SCR26=1 AND SCR24a=1) GO TO SCR30 AND CODE AS ELIGIBLE.

IF (SCR24=2 AND SCR24a=1) OR (SCR26=2 AND SCR24a=1) N GO TO SCR27a-b.

IF (SCR24=3 AND SCR24a=1) OR (SCR26=3 AND SCR24a=1) GO TO SCR27a-b.

IF SCR24a=2, GO TO SCR28.

SCR25. [IF SCR20c = 2]

IF CALC_ELIG=1, FILL_SCR13=NAME_ELIG.

IF CALC_ELIG>1, FILL_SCR25= “the children”

May I speak with [FILL_SCR25]’s parent or guardian?

1 YES

2 NOT NOW, BUT LATER

3 NO, REFUSAL TO INTERVIEW

9 DK/ REF

ASK: All respondents who are not the parent or legal guardian of the eligible youth.

PROGRAMMER: IF SCR25=1, GO TO SCR26. IF SCR25 = 2 THEN GO TO SCR27a-b. IF SCR25=3, GO TO SCR28.

SCR26. [IF SCR20c=2 OR SCR21e=2, OR SCR23a_i=2 OR SCR23b_i=2 OR SCR25=1]

PROGRAMMER: IF CALC_ELIG=1, FILL_SCR26= “your child has”.

IF CALC_ELIG>1, FILL SCR26= “your children have”.

[ONCE PARENT/GUARDIAN IS AVAILABLE]

Hello, my name is [FI_NAME] from RTI International in North Carolina. We are conducting a national study of youth to ask their opinions related to health and advertisements they may have seen on TV and online. Based on answers to the screening questions, [FILL_SCR26] has been selected for the study. I’d like to explain the study and how you may be able to help us. If this is a good time, we could get started. I have some information for you about the study and I will need a place to set up a laptop computer.

1 YES

2 NONE OF THE CHILDREN ARE AVAILABLE NOW, BUT PARENT/LEGAL GUARDIAN IS AVAILABLE

3 CHILDREN AND PARENT/ LEGAL GUARDIAN NOT AVAILABLE NOW, RESCHEDULE FOR LATER

4 NO, REFUSAL TO INTERVIEW

9 DK/ REF

ASK: parent or legal guardian of the eligible youth(s) who came forward after being identified as the parent or legal guardian.

PROGRAMMER: IF SCR26=1, GO TO SCR24a. IF SCR26=2, GO TO SCR24a. IF SCR26=3, GO TO SCR27a-b. IF SCR26=4 GO TO SCR28.

SCR27a-b. [IF SCR3a=2 SCR18=2 OR SCR21c=2 OR SCR23a_i=3 OR SCR23b_i=3 OR SCR24=3]

Let me schedule a convenient time to come back. First what would be a good date?

ENTER MONTH AND DAY HERE; ENTER TIME ON THE NEXT SCREEN.

SCR27a MONTH ____

SCR27b DAY ____

DK/REF

ASK: all respondents who need to schedule an appointment for the interviewer to come back.

PROGRAMMER: MONTH DROPDOWN 1-12. DAY DROPDOWN 1-31. DO NOT ALLOW INVALID DATES SUCH AS FEBRUARY 30, APRIL 31, JUNE 31, ETC.

SCR27c- SCR27e. [IF SCR27a-b>0]

(Let me schedule a convenient time to come back.)

What would be a good time on [SCR27a] [SCR27b]?

SCR27c HOUR ____

SCR27d MINUTES _____

SCR27e

1 AM

2 PM

DK/REF

ASK: all respondents who need to schedule an appointment for the interviewer to come back.

PROGRAMMER: ALLOW HOUR 1-12. ALLOW MINUTES 00-59. LET AM AND PM BE CHECKBOXES.

SCR27f. [IFSCR27a-b>0]

PROGRAMMER: IF SCR3a=2 OR SCR18=2, FILL_SCR27f= “me to return to complete the brief screening questions”

IF SCR24=2 OR SCR25=2 OR SCR26=2, FILL_SCR27f= “the interview”

IF SCR20c=3 OR SCR21e=3 OR SCR23a_i=3 OR SCR23b_i=3, FILL_SCR27f= “me to return to interview the parent or legal guardian and to get their permission to interview the eligible youths.”

Thank you for setting an appointment for [FILL_SCR27f]. I will return on [SCR27a] [SCR27b] at [SCR27c]:[SCR27d] [SCR27e].

ASK: all respondents who scheduled an appointment for the interviewer to come back.

PROGRAMMER: UPON COMPLETING SCR15a-f, GO TO SCR30.

ELSE, GO TO SCRFINISH.

SCR28. [IF SCR18=3 OR SCR120c=4 OR SCR21e=4 ORSCR23a_i=4 OR SCR23b_i=4 OR SCR24=4 OR SCR24a=4 OR SCR25=3 OR SCR26=4]

Thank you for your time and consideration. I have just a few more questions if you can spare just a couple more minutes. Can you tell me more about your reasons for not participating in this study?

___________________ [ALLOW 100 CHARACTERS]

DK/REF

ASK: all respondents who are refusing to complete the interview.

PROGRAMMER: UPON COMPLETING SC286, GO TO SCR30.

SCR29a-b [IF SCR3a=3 OR SCR3a=9 OR SCR19c= 0]

I’m sorry, but based on your answers to the screening questions no one in your household is eligible to participate in this study. Thank you for taking the time to answer these screening questions. So that my supervisor may check the quality of my work, please give me just your first name and telephone number.

IF THE SR REFUSES TO ANSWER, ENTER 99

SCR29a. <FIRST NAME> _________ [ALLOW 20 CHARACTERS]

DK/REF

SCR29b.<TELEPHONE NUMBER> ___________ (APPLY 3-3-4 FORMAT)

DK/REF

ASK: all respondents provide answers that indicate the household is not eligible.

SCR30.

Those are all the questions I have. Thank you for your assistance.

[PROGRAMMER: IF SCR24a=1 DO NOT SHOW THE TEXT “Those are all the questions I have. Thank you for your assistance.”

INTERVIEWER: THE REMAINING 2 QUESTIONS ARE TO BE RECORDED BY OBSERVATION.

PRESS NEXT TO CONTINUE

ASK: all respondents

SCR31.

INTERVIEWER RECORD SCREENING RESPONDENT’S GENDER

1 MALE

2 FEMALE

ASK: not asked to respondents

SCR32.

[PROGRAMMER: ALL SCREENINGS WILL ANSWER] INTERVIEWER RECORD PRIMARY LANGUAGE USED FOR THIS SCREENING

1 ENGLISH

2 SPANISH

ASK: not asked to respondents

SCRFINISH

TAP “EXIT” TO EXIT TO CASE MANAGEMENT SYSTEM (CMS) OR “BACK” TO GO BACK.

PRESS 1 TO EXIT SCREENER

PROGRAMMER: MAKE SURE THAT IN THE CASE OF MULTIPLE CHILDREN WITH DIFFERENT SETS OF PARENTS, THE SCREENER DOES NOT END AFTER THE FIRST PARENT. IT SHOULD GO BACK TO SCR11a_i or SCR11b_i (DEPENDING ON THE CONTEXT).

Programming Specifications 10-23-2015

Programmer Notes:

• Program should capture time/date stamp at start of survey.

• Section headings should not appear in the instrument.

• Variable names should not appear before the question on the screen. They should be in a corner and will be used for testing purposes.

• In the case of a table such as A1, variables A1_1- A1_10 could instead be numbered 1-5.

• Response option boxes (i.e. ₁) are for display only. They should not have the number right next to it on the screen.

• In a table, when the header has “1 Definitely Yes,” “2 Probably Yes,” etc. make sure that the numbers do not appear in the instrument. These are for back-end purposes only.

• Only one question should appear per screen, except where there is a grid, or an intro.

• Make sure that all questions should fit in a screen. Respondents should not have to scroll on a given page.

• Make sure that the “Prefer not to answer” response is only shown when a respondent tries to skip a question. First, a soft check pop-up screen will appear that says “This question is important to the survey. If you meant to leave it blank, just continue. Otherwise, please answer it.” After the screen shows up, show the response options with the “Prefer not to answer” option.

• Make sure that the “Prefer not to answer” response option is clearly marked that it is separate from the other response options. One way, we can do this is by having an extra space between the response options and the “Prefer not to answer” response option. See A2 as an example for single items. See A1 for table formats.

• Respondents may not move backward within a survey. The testing version of the survey should have a Previous button to allow testers to back up.

• Range checks will be a soft check unless otherwise noted.

• For all entries that are keyed numbers, only accept blank or numeric values. If an alpha is keyed and there is no specific numeric range check, please display hard check, “Please enter a number.” Otherwise, the check will also include the valid numeric range.

• For all radio button questions, include an “uncheck” box.

• Respondents will be permitted to “pause” a survey at any point in the survey and then return to complete the survey at a later time. This should not have implications for programming.

• “Next” buttons will be displayed on every survey screen as appropriate.

• All images should be arrange in such a way that focus on usability and layout. Images should be aligned and of similar sizes as one another.

Fills:

IF CALC_ELIG=1, THEN YOUTH_NAME=[NAME_ELIG].

IF CALC_ELIG>1, THEN YOUTH_NAME_i=[NAME_ELIG_i].

INTRO

PROGRAMMER:

IF CALC_ELIG=1, FILL_INTRO= “your child has”.

IF CALC_ELIG>1, FILL INTRO= “your children have”.

We are conducting a national study of youth to ask their opinions related to health and advertisements they may have seen on TV and online. Based on answers to the screening questions, [FILL_INTRO] been selected for the study. We would like to ask you a few questions about your household’s characteristics and media use. You can refuse to answer any questions, and you can quit at any time.

If you have any questions about the study, please contact the ExPECTT project assistance line, toll-free at [ADD TOLL FREE PHONE NUMBER]. If you have a question about your rights as a study participant, call toll-free: RTI’s Office of Human Research Protections at 1-866-214-2043.

INTRO1

We will be asking you about media consumption of [CHILD NAME]. Would you consider yourself to be knowledgeable in responding to items about the [CHILD NAME]?

₁ Yes.

₂ No.

[IF INTRO1=2]

INTRO2

PROGRAMMER: IF CALC_ELIG=1, FILL_INTRO2= “CHILD 1 NAME”.

IF CALC_ELIG>1, FILL INTRO2= “CHILD 1 NAME AND CHILD 2 NAME, ETC”.

₁ Yes.

₂ No.

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.

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