General Population Screener and Consent Process (Youth and Parent)

Attachment 3_E2b2: Parent or Guardian Mail Screener B

Form Approved

OMB No. 0910-0753

Exp. Date 09/30/2019

RIHSC No. 17-XXXCTP

Who should complete this survey?

• An adult 18 years old or older, living or staying at this address for more than 2 months, who is knowledgeable about this home should complete this survey.

• Please do not have an adult who is only visiting the home temporarily complete this survey. When answering the questions, please do not include anyone who is away at school or away in the military or anyone who is visiting temporarily.

If NO ONE in the household meets these criteria

PLEASE RETURN THE SURVEY IN THE ENCLOSED ENVELOPE

Survey Instructions

Please use a blue or black pen to complete this survey.

Mark your response by filling in the area () or marking an X ().

Survey Questions

The first few questions are about people who live or stay in this home.

1. Including you, how many adults 18 years old or older live or stay at this address?

• INCLUDE all adults 18 years old or older who are living or staying here for more than 2 months.

• INCLUDE all adults 18 years old or older staying here who do not have another place to stay, even if they are here for 2 months or less.

• DO NOT INCLUDE anyone who is living somewhere else for more than 2 months, such as a college student living away or someone in the Armed Forces on deployment.

• 1

• 2

• 3

• 4

• 5

• 6

• 7 or more

ASK: All respondents

2. Including you, how many adults (18 years or older) living or staying in this home are in each age group? (Mark an answer for each row)

	Number of Adults Including You
	0	1	2	3 or more
Age 17-24	○	○	○	○
Age 25-54	○	○	○	○
Age 55+	○	○	○	○

ASK: All respondents

3. How many children living or staying in this home are in each age group? (Mark an answer for each row)

	Number of Children
	0	1	2	3 or more
Age 0-5	○	○	○	○
Age 6-10	○	○	○	○
Age 11-16	○	○	○	○

ASK: All respondents

4. Including you, how many adults 18 years old and older living or staying in this home… (Mark an answer for each row)

	Number of Adults Including You
	0	1	2	3 or more
Have an Associates, Bachelor’s, graduate or professional degree	○	○	○	○
Attended some college but do not have a degree	○	○	○	○
Have a high school diploma or GED or less.	○	○	○	○

ASK: All respondents

5. Is anyone living or staying in this home of Hispanic, Latino or of Spanish origin?

○ Yes

○ No

ASK: All respondents

6. Is anyone living or staying in this home...

9a. White?

○ Yes

○ No

9b. Black or African-American?

○ Yes

○ No

9c. Asian or Pacific Islander?

○ Yes

○ No

ASK: All respondents

The next questions are about your home.

7. Is this home…

○ Owned by you or someone in your household

○ Rented

○ Occupied without payment of rent

ASK: All respondents

8. Which best describes the language spoken in your home?

○ English only

○ Mostly English

○ Mostly Spanish

○ Mostly another language

ASK: All respondents

9. Do you or any member of this household have access to the Internet using a…

12a.Cellular data plan for a smartphone or other mobile device?

○ Yes

○ No

12b. Broadband (high speed) Internet service such as cable, fiber optic, or DSL service installed in this household?

○ Yes

○ No

12c. Satellite Internet service installed in this household?

○ Yes

○ No

12d. Dial-up Internet service installed in this household?

○ Yes

○ No

12e. Some other service?

○ Yes

○ No

ASK: All respondents

10. 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

The next question is about cigarette smoking.

11. Do any of the adults (18 and older) living or staying in this home currently smoke cigarettes?

○ Yes

○ No

ASK: All respondents

UniverseText:

You have reached the end of the survey.

Thank you for your time.

Please return this survey to RTI in the postage-paid, addressed envelope we have provided.

Or mail to:

RTI International

Research Operations Center

5265 Capital Boulevard

Raleigh, NC 27690-1653

Data Capture (FILL PROJECT CODE)

If you have questions, please call {PROJECT 1-800 NUMBER}

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 5 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.