OMB No. 0910-####
Exp. Date XX/XX/XXXX
RIHSC No. 17-082CTP
Programming conventions and specifications notes
Don’t Know/Refused are not allowed in combination with other responses.
Response options should not be labeled with numbers.
Bolding conveys emphasis while capital letters convey instructions for interviewers or programmers (in brackets).
Questionnaire will include a progress bar.
All items are required.
“Next” buttons will be displayed on every survey screen as appropriate.
All images should be arranged in such a way that focus on usability and layout. Images should be aligned and of similar sizes as one another.
CASE SELECTION SCREEN
Items shown on the case selection screen
CASEID
STATUS CODE
STREET ADDRESS(including apartment #)
CITY, STATE ZIP
ELIGIBLE MAIL SCREENER
CONTACT LEVEL FLAG
[DRILL DOWN FIELD]
Case Details Screen
Initiate Interview
Record of Calls
Edit Address
View Address Changes
Add Case Notes
Show on Map
CASE DETAILS SCREEN
CASEID
STATUS CODE
STREET ADDRESS (including apartment #)
CITY, STATE ZIP
NAME OF SELECTED SAMPLE HOUSEHOLD MEMBER [SCF2 IF DATA PRESENT; ELSE SCC4_n]
AGE OF SELECTED SAMPLE HOUSEHOLD MEMBER
PHONE [IF SCREENING COMPLETE, SCF9; ELSE SCEXIT3END_PHONE]
[UPDATE FIELDS WITH INFORMATION OF ALTERNATE IF PRIMARY IS RENDERED INELIGIBLE]
QUEXCODE
Timestamp Specs
Overall time for respondents – INTRODUCTION through SCBEGIN OR SCEXIT3END
Overall time by section
SECTION A – INTRODUCTION
SECTION B & C– SCB1 through SCB4
SECTION C - SCBCONSENT
SECTION C – SCB5 through SCB8 or SCB8A
SECTION D & E – SCC1 through SCD2
SECTION G – SCF1 through SCF9
INTRODUCTION
[SET STATUS CODE ON CASE TO 1037 – CASE ACCESSED]
CONFIRM YOU HAVE OPENED THE CORRECT CASE. IF YOU ARE NOT IN THE CORRECT CASE, BREAK OFF AND LOCATE THE CORRECT CASE.
[And the following statement at the very bottom of the screen in small font:]
OMB No. 0910-####
Exp. Date XX/XX/XXXX
RIHSC No. 17-082CTP
Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 10 minutes per response to complete the survey questions. Send comments regarding this burden estimate or any other aspects of this information collection, including suggestions for reducing burden, to PRAStaff@fda.hhs.gov.
SCBLANG. INTERVIEWER: WHAT LANGUAGE IS BEING USED TO CONDUCT THIS INTERVIEW? IF OTHER, ASK TO SPEAK TO ENGLISH SPEAKER.
1 ENGLISH
2 OTHER (NO ENGLISH SPEAKER AVAILABLE) GO TO SCEXIT3.
ASK: All screeners
ADDRESS VERIFICATION
SCB1. Hello, my name is __________ from RTI International in North Carolina. We are conducting a nationwide study sponsored by the U.S. Food and Drug Administration (FDA). Your household was recently sent a survey with a letter attached to it.
[IF NEEDED] HAND R COPY OF LETTER EXPLAINING THE STUDY.
ASK: All screeners
SCB2. First, let me verify: Do you live here?
1 YES
2 NO
-1 DON’T KNOW
-2 REFUSED
ASK: All screeners
SCB3. [IF SCB2=YES]
IF NECESSARY: Are you 18 or older?
1 YES
2 NO
-1 DON’T KNOW
-2 REFUSED
ASK: Screeners who report living at the sample address
SCB3a. [IF (SCB2=2 OR SCB2=DK/REF) OR (SCB3=2 OR SCB3=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
2 YES, BUT NEED TO SCHEDULE
3 NO, NO ONE LIVING HERE 18 OR OLDER
-1 DON’T KNOW
-2 REFUSED
[PROGRAMMER: IF SCB3a=1 THEN SKIP BACK TO SCB1. IF SCB3a=2, GOTO SCEXIT2. IF SCB3a=3 THEN SKIP TO SCEXIT3. IF SCB3a=-1 OR -2, GO TOSCEXIT3END.]
ASK: Screeners who either report not living at the sample address or are less than 18 years of age
ADDRESS VERIFICATION
SCB4. HAND R COPY OF LETTER AND THE MAIL SCREENER. ALLOW TIME TO READ.
For survey purposes, I need to confirm that I have the correct address. Is this [FILL ADDRESS]?
1 YES, VERIFIED ADDRESS IS CORRECT
2 NO, EXIT AND FIND CORRECT ADDRESS GO TO SCEXIT1
3 ADDRESS CORRECT, MINOR EDITS NEEDED. GO TO SCEXIT1A
ASK: All screeners that report for adult status and confirm address
SCBCONSENT. SCREENER INFORMED CONSENT:
We are working with the FDA to conduct interviews for a research study. This address is one of approximately 12,000 households across the U.S. that we expect to screen. We are contacting this household to determine if anyone who lives here may qualify for a study on ads that people may have seen and what they think about these ads.
My questions will only take 5-10 minutes of your time. Your answers to the questions will be kept private as much as possible according to the law, and your participation is completely optional. If, after the 5 to 10 minute survey, we select someone from your household to take part in the study, that person will have the chance to complete a separate 30 minute interview today and receive $25.
CONTINUE GO TO CARICONSENT
ASK: All screeners that report for adult status and confirm address
CARICONSENT
We are using a special quality control system that will record what we say to each other to ensure I am following the correct procedures. The recording will be reviewed to monitor the quality of my work. The recordings will be deleted after my work has been reviewed and will be kept private. You can still participate even if you do not agree to this recording.
May we use this quality control recording system?
1=YES
2=NO
[IF NO, DEACTIVATE COMPUTER AUDIO RECORDED INTERVIEWING FOR THIS CASE]
ASK: All screeners that report for adult status and confirm address
SCB5. Are there any other living quarters within this structure or at this address, such as a separate apartment with a separate entrance?
1 YES
2 NO GO TO SCC1
[PROGRAMMER: PASSIVE CAPTURE GPS COORDINATES TO ALLOW VERIFICATION THAT SCREENER TOOK PLACE AT RECORDED ADDRESS]
[INITIATE CARI RECORDING IF CARICONSENT = 1]
ASK: All screeners that report for adult status and confirm address
SCB6. Do the occupants of the other living quarters live and eat separately from the residents of this household? (PROBE IF NEEDED: In other words, do the occupants live on their own or do they share common space and food?)
1 YES, OCCUPANTS LIVE SEPARATELY
2 NO, OCCUPANTS SHARE COMMON FOOD/SPACE GO TO SCC1
ASK: Screeners that report multiple living quarters at the sampled address
SCB7. Do the occupants of the additional living quarters have direct access to the residence from the outside or through a common hall?
1 YES
2 NO go to SCC1
[END CARI RECORDING IF CARICONSENT = 1]
ASK: Screeners that report multiple living quarters at the sampled address that do not share a common food space
SCB7A. INTERVIEWER: DID YOU FIND 5 OR MORE NEW LIVING QUARTERS?
1 YES GO TO SCB8A
2 NO
ASK: Screeners that report multiple living quarters at the sampled address that do not share a common food space and have direct access to the residence from the outside or a common hall
SCB8KNOWN
[PROGRAMMER: LOOP SCB8KNOWN TO SCB8MORE FOUR TIMES]
INTERVIEWER: IS THE ADDRESS OF THE LIVING QUARTERS KNOWN
1 YES
2 NO
ASK: Screeners that report multiple living quarters at the sampled address that do not share a common food space and have direct access to the residence from the outside or a common hall
SCB8NUM. [SCB8KNOWN = YES]
INTERVIEWER: OCCUPANTS OF ADDITIONAL LIVING QUARTERS LIVE ON OWN AND HAVE DIRECT ACCESS FROM OUTSIDE/COMMON HALL. ENTER ADDRESS OF SEPARATE LIVING QUARTERS.
INCLUDE STREET NUMBER, NAME, AND UNIT OR APARTMENT NUMBER.
STREET NUMBER:
[500 CHAR]
ASK: Screeners that report multiple living quarters at the sampled address that do not share a common food space and have direct access to the residence from the outside or a common hall when the address is known
SCB8NAME [SCB8KNOWN = YES]
INTERVIEWER: OCCUPANTS OF ADDITIONAL LIVING QUARTERS LIVE ON OWN AND HAVE DIRECT ACCESS FROM OUTSIDE/COMMON HALL. ENTER ADDRESS OF SEPARATE LIVING QUARTERS.
INCLUDE STREET NUMBER, NAME, AND UNIT OR APARTMENT NUMBER.
STREET NAME & UNIT/APARTMENT#:
[500 CHAR]
ASK: Screeners that report multiple living quarters at the sampled address that do not share a common food space and have direct access to the residence from the outside or a common hall when the address is known
SCB8DESC [SCB8KNOWN = NO]
INTERVIEWER: RECORD A DESCRIPTION OF THE LIVING QUARTERS]
[500 CHAR]
ASK: Screeners that report multiple living quarters at the sampled address that do not share a common food space and have direct access to the residence from the outside or a common hall when the address is not known
SCB8MORE
INTERVIEWER: ARE THERE ADDITIONAL LIVING QUARTERS TO RECORD
1 YES GO TO SCBKNOWN
2 NO
ASK: Screeners that report multiple living quarters at the sampled address that do not share a common food space and have direct access to the residence from the outside or a common hall
SCB8A. [IF SCB7A = 1]
PLEASE COLLECT DETAILED INFO ABOUT ADDITIONAL LIVING QUARTERS (5+ LIVING QUARTERS) AND CONTACT YOUR FS UPON LEAVING THE HOME.
[500 CHAR]
CONTINUE GO TO SCC1
ASK: Screeners that report 5 or more living quarters at the sampled address that do not share a common food space and have direct access to the residence from the outside or a common hall
HOUSEHOLD ROSTER
SCC1. INTERVIEWER: RECORD THE BEST DESCRIPTION OF THE ADDRESS: (MARK ONLY
ONE, IF NUMBER OF UNITS UNKNOWN, PROMPT RESPONDENT).
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
[INITIATE CARI RECORDING IF CARICONSENT = 1]
ASK: All screeners that report for adult status and confirm address
SCC2. Next I would like to ask a few questions about you and your household.
First, are there any children 17 years or younger living in this home?
1 YES
2 NO
ASK: All screeners that report for adult status and confirm address
SCC3. Including yourself, how many adults 18 years old or older are living at this address?
[IF SCB5 = 1, FILL]: [Please do not include persons who live on their own in separate living quarters at this address or within this structure, such as a separate apartment with a separate entrance.] Please do not include anyone who is away at school or away in the military or anyone who is visiting temporarily.
[FILL SAMPLE ADDRESS FOR REFERENCE. USE UPDATED ADDRESS FROM SECTION A IF APPLICABLE.]
INTERVIEWER PROBE IF NEEDED:
INCLUDE adults who usually stay here but are temporarily away for reasons such as visiting friends, traveling for their jobs, or in “general” hospitals.
[DISPLAY IF SCB6 = 2]: INCLUDE adults who share common food or space but live in other living quarters at the address.
_____ NUMBER OF ADULTS [RANGE 01-10]
[PROGRAMMER: LOOP SCC4 AS MANY TIMES AS SCC3 (I.E., THE NUMBER OF ADULTS. FIRST LOOP IS IDENTIFIED AS LOOP 1, ALL OTHERS LOOP 2.]
[END CARI RECORDING IF CARICONSENT = 1]
ASK: All screeners that report for adult status and confirm address
SCC4. [IF LOOP 1]: What is your name?
[IF LOOP 2+]: Please give me the names of all the other adults ages 18 and older who live or stay at this address. Let’s start with the oldest and work down to the youngest adult in this age range in the household.
INTERVIEWER: ASK FOR FULL NAMES, BUT ACCEPT FIRST NAMES, NICKNAMES OR INITIALS IF NECESSARY. TRY TO DISTINGUISH NAMES (Tom vs. Tom Jr.). ASSURE R OF PRIVACY.
SCC4_n |
[NAME_1] |
[ALLOW 50 CHARACTERS] |
|
ASK: All screeners that report for adult status and confirm address
SCC5. [IF SCC3 > 01]
Do any other adults 18 years old or older usually live here or stay here?
1 YES GO TO SCC4a
2 NO GO TO CHECK BOX 1
ASK: Screeners that report more than 1 adult living at the sample address
CHECK BOX 1: IF SCC3 = 01 GO TO SCC7 |
SCC6. Please tell me the name of the adult or one of the adults living here who owns or rents this home. We’ll refer to this person as the “head of household.”
INTERVIEWER: PICK “HEAD OF HOUSEHOLD” FROM DISPLAYED ROSTER. IF SCREENING RESPONDENT IS ONE OF THE “HEAD OF HOUSEHOLDS,” SELECT HIM/HER FROM ROSTER.
[PROGRAMMER: IDENTIFY SELECTED “HEAD OF HOUSEHOLD” AS “HHNAME” FILL.]
ASK: Screeners that report more than 1 adult living at the sample address
SCC7. Is this home owned by you or someone in your household, rented, or occupied without payment of rent?
1 OWNED BY YOU OR SOMEONE ELSE IN THE HOUSEHOLD
2 RENTED
3 OCCUPIED WITHOUT PAYMENT OR RENT
[INITIATE CARI RECORDING IF CARICONSENT = 1]
ASK: Screeners that report more than 1 adult living at the sample address
SCC8. Which of the following languages are spoken in this home? [READ LIST]
1 English
2 Spanish
3 Other Languages
[END CARI RECORDING IF CARICONSENT = 1]
IF SCC3 = 01 GO TO CHECKBOX2
ASK: Screeners that report more than 1 adult living at the sample address
SCC9INTRO. Now I have a few questions about the adults who live in this household. Let’s start with you.
CONTINUE GO TO CHECK BOX 2
ASK: Screeners that report more than 1 adult living at the sample address
CHECK BOX 2:
IF ROSTER CONTAINS ONLY 1 ADULT CODE THE ADULT AS “HEAD OF HOUSEHOLD (0)” IN SCC9 AND GO TO SCC10.
IF ROSTER CONTAINS 2 OR MORE ADULTS ASK SCC9-SCD1 FOR EACH ADULT ON LIST 1. |
SCC9. [IF LOOP NE HEAD OF HOUSEHOLD]
[IF LOOP 1 (SCREENING R)]: How are you related to the head of household, [FILL HHNAME NAME]?
[IF LOOP 2+]: Now let's talk about the other adults in the household. How is [FILL NAME] related to [IF SCREENING R IS HEAD OF HOUSEHOLD IN SCC11, FILL: “you”/ELSE, FILL “[HHNAME]”?]
1 SPOUSE
2 SON (INCLUDES STEP, ADOPTED, OR FOSTER)
3 DAUGHTER (INCLUDES STEP, ADOPTED, OR FOSTER)
4 SON-IN-LAW/DAUGHTER-IN-LAW
5 BROTHER (INCLUDES STEP, ADOPTED, OR FOSTER)
6 SISTER (INCLUDES STEP, ADOPTED, OR FOSTER)
7 PARENT/GUARDIAN (INCLUDING STEP, ADOPTED, OR FOSTER)
8 GRANDPARENT
9 GRANDCHILD
10 LIVE-IN PARTNER
11 FRIEND/ROOMMATE
12 OTHER RELATIVE
13 OTHER NON-RELATIVE
14 RELATIONSHIP UNSPECIFIED
-1 DON’T KNOW
ASK: All screeners that report for adult status and confirm address
SCC10. INTERVIEWER: ASK IF UNSURE: What is [IF LOOP 1]: your/[IF LOOP 2+] [FILL
NAME]’s gender?
1 MALE
2 FEMALE
3 OTHER (PLEASE STATE)________
-1 DON’T KNOW
ASK: All screeners that report for adult status and confirm address
SCC11. [IF LOOP 1]:
What is your age?
[IF LOOP 2+]:
What is the age of [FILL NAME]?
INTERVIEWER: ENTER -1 FOR DON'T KNOW, ENTER -2 FOR REFUSED
_____ AGE [RANGE: 18-110]
-1 DON’T KNOW
-2 REFUSED
ASK: All screeners that report for adult status and confirm address
SCC11A. [IF SCC11 = DK / REF]
Providing an age is important. This ensures we can accurately determine whether [IF LOOP 1]: you are/ [IF LOOP 2+]: [fill person name] is eligible to participate in the panel. Can you confirm which of the following age categories [IF LOOP 1]: you belong/[IF LOOP 2+]: [fill person’s name] belongs] to?
1 18-24
2 25-34
3 35-44
4 45-54
5 55 or older
-1 DON’T KNOW
-2 REFUSED
ASK: Screeners who initially do not report an age for screener or individual being rostered
SCC12. [IF LOOP 1, FILL]: Are you/ELSE: Is [FILL NAME]] currently serving on active duty in the U.S. Armed Forces, Military Reserves or National Guard? [FILL FOR LOOP 1 ONLY]: Active duty for the Reserves or National Guard does not include the regular training for the Reserves or Guard. It does include being activated for deployment such as for the Iraq War.
1 YES
2 NO
-1 DON’T KNOW
INTERVIEWER: IF ASKED, THE US ARMED FORCES ARE ARMY, NAVY, AIR FORCE, AND MARINE CORPS.
ASK: All screeners that report for adult status and confirm address
SCC14. What is the highest grade or year of school [IF LOOP 1, FILL "you have", ELSE FILL "[NAME] has"] completed?
INTERVIEWER: FOR THOSE CURRENTLY IN SCHOOL, THIS DOES NOT INCLUDE THE CURRENT YEAR OF SCHOOL, UNLESS IT IS ALREADY COMPLETED.
1 NO HIGH SCHOOL DIPLOMA OR EQUIVALENT (GED)
2 HIGH SCHOOL DIPLOMA OR GED BUT DID NOT ATTEND COLLEGE
3 ATTENDED COLLEGE BUT NO DEGREE
4 HAVE AN ASSOCIATES, BACHELOR’S, GRADUATE OR PROFESSIONAL DEGREE
-1 DON’T KNOW
ASK: All screeners that report for adult status and confirm address
SCC15. [IF LOOP 1, FILL "Are you", ELSE FILL "Is [NAME]"] Hispanic, [IF SCC10 =1, FILL: Latino / IF SCC10 = 2, FILL: Latina / IF SCC10 = 3, FILL: Latino or Latina], or of Spanish origin?
1 YES
2 NO
-1 DON’T KNOW
ASK: All screeners that report for adult status and confirm address
SCC16. What is [IF LOOP 1, FILL "your", ELSE IF SCC10 = 1, FILL: his/IF SCC10 = 2, FILL her /IF SCC10 = 2, FILL their] race? I'm going to read a list. Please select one or more.
1 WHITE
2 BLACK OR AFRICAN AMERICAN
3 ASIAN
4 OTHER
-1 DON’T KNOW
ASK: All screeners that report for adult status and confirm address
SCC17. [IF LOOP 1, FILL "Do you", ELSE FILL "Does [NAME]"] live here full time or part time? By full time we mean [IF LOOP 1, FILL you spend, ELSE FILL [NAME] spends] half or more of [IF LOOP 1, FILL "your", ELSE IF SCC10=1, FILL "his", ELSE IF SCC10 = 2, FILL "her", ELSE IF SCC10 = 2, FILL their] time in this household?)
1 FULL TIME (SPENDS HALF TIME OR MORE IN THIS HH)
2 PART TIME (SPENDS LESS THAN HALF TIME IN THIS HH)
-1 DON’T KNOW
ASK: All screeners that report for adult status and confirm address
Tobacco use question
SCD1. The next question is about tobacco products (IF LOOP 1, FILL "you use"/ELSE FILL "[NAME] uses") and how often (IF LOOP 1, FILL "you use" if SR; ELSE FILL "he uses” if Male “she uses” if Female) them.
[IF LOOP 1, FILL: Do you/ELSE FILL: Does [NAME]] smoke cigarettes every day, some days, or not at all?
1 EVERY DAY
2 SOME DAYS
3 NOT AT ALL
-1 DON’T KNOW
-2 REFUSED
ASK: All screeners that report for adult status and confirm address
SCD2. Do you or any member of your household subscribe to the internet?
INTERVIEWER: IF ASKED, SOME COMMON WAYS OF SUBSCRIBING TO THE INTERNET INCLUDE DIAL-UP SERVICE, DSL SERVICE, CABLE MODEM SERVICE, FIBER OPTIC SERVICE, MOBILE BROADBAND PLAN FOR A COMPUTER OR A CELL PHONE, SATELLITE INTERNET SERVICE, OR SOME OTHER SERVICE.
1 Yes
2 No
-1 DON’T KNOW
-2 REFUSED
ASK: All screeners that report for adult status and confirm address
PANEL MEMBER SELECTION
CHECK BOX 4:
PROMPT COMPUTER TO RANDOMLY SELECT SAMPLED ADULT AT THIS POINT. SELECT 1 ALTERNATE ELIGIBLE IN HH (IF ANY) IN CASE FIRST SAMPLED ADULT IS INELIGIBLE PER FI ENROLLMENT SURVEY MODULE. ONCE SELECTED, GO TO SCF1. ELSE, IF NO ELIGIBLES IN HH, GO TO SCEXIT3.
ANY PERSON � 25 to 54 years old AND � NOT ON ACTIVE DUTY (SCC8 = 2) AND � LIVES IN HH FULL TIME (SCC17=1) AND � CURRENT CIGARETTE SMOKER (SCD1=1 OR 2)
CREATE FILLS FOR SAMPLED ADULT’S NAME. IF PRIMARY IS LATER DETERMINED INELIGIBLE, REPLACE FILLS WITH NAME FOR ALTERNATE.
IF ALL ADULTS ARE INELIGIBLE, GO TO SCEXIT3. |
ENROLLMENT
SCF1. The computer has selected [IF SCREENER SELECTED, FILL you, ELSE FILL DISPLAYED SAMPLED ADULT] for the study. I want to make sure I have (your/his/her) full name before we continue.
[DISPLAY NAME, AGE, GENDER OF SAMPLED ADULT SO FI ASKS FOR CORRECT PERSON]
INTERVIEWER: UPDATE NAME AS NEEDED.
1 NAME CORRECT AS IS [SCREENER GO TO SCF9; ELSE GO TO SCF2A]
2 UPDATE NAME
ASK: Randomly selected sample member or screener reporting on sample member
SCF2. INTERVIEWER: PLEASE OBTAIN/VERIFY [SAMPLED ADULT]’s FULL NAME.
NAME: _________________________________ [SCREENER GO TO SCF9; ELSE SCF2A]
ASK: Randomly selected sample member or screener reporting on sample member
SCF2A. [SELECTED ADULT IS NOT SCREENER] INTERVIEWER: OBTAIN A GOOD PHONE NUMBER FOR THE SCREENER IF NOT SAMPLED ADULT.
So that my supervisor may check the quality of my work, can I have a telephone number they may call you back at?
PHONE NUMBER: ______________________________
ASK: Screener that is not the selected sample member
SCF2B. INTERVIEWER: ASK TO SPEAK WITH SAMPLED ADULT IF DIFFERENT FROM SCREENING RESPONDENT.
1 SELECTED ADULT IS UNAVAILABLE GO TO SCEXIT3C.
2 SELECTED ADULT IS AVAILABLE
ASK: All screeners
SCF4. We are working with the FDA to conduct interviews for a research study. This address is one of approximately 12,000 households across the U.S. that we expect to screen. We are contacting this household to determine if anyone who lives here may qualify for a study on ads that people may have seen and what they think about these ads. Based on [SCREENER’S NAME] answers to my earlier questions, you were selected to take part in the study. If you qualify for our study, you will have the chance to complete a 30 minute interview today and receive $25.
But first, I just need to ask you a few questions to make sure you are eligible for the study. What is your age?
_____ AGE [RANGE: 18-110]
-1 DON’T KNOW
-2 REFUSED
ASK: Selected sample member
SCF5. [IF SCF4 = DK / REF] Providing an age is important. This ensures we can accurately determine whether you are eligible to participate in the panel. Can you confirm which of the following age categories you belong to?
1 18-24
2 25-34
3 35-44
4 45-54
5 55 or older
-1 DON’T KNOW GO TO scexit3d
-2 REFUSED GO TO scexit3d
ASK: Selected sample member who does not initially report an age
SCF3. INTERVIEWER: PLEASE VERIFY [primary sampled adult]’s GENDER.
1 MALE
2 FEMALE
3 OTHER (PLEASE STATE)________
ASK: Selected sample member meeting age eligibility
SCF6. Are you currently serving on active duty in the U.S. Armed Forces, Military Reserves or National Guard? Active duty for the Reserves or National Guard does not include the regular training for the Reserves or Guard. It does include being activated for deployment such as for the Iraq War.
1 YES GO TO SCEXIT3D
2 NO
INTERVIEWER: IF ASKED, THE US ARMED FORCES ARE ARMY, NAVY, AIR FORCE, AND MARINE CORPS.
[INITIATE CARI RECORDING IF CARICONSENT = 1]
ASK: Selected sample member meeting age eligibility
SCF7. Do you live here full time or part time? By full time we mean you spend half or more of your time in this household.
1 FULL TIME (SPENDS HALF TIME OR MORE IN THIS HH)
2 PART TIME (SPENDS LESS THAN HALF TIME IN THIS HH) GO TO SCEXIT3D
ASK: Selected sample member meeting age and military status eligibility
SCF8. Do you smoke cigarettes every day, some days, or not at all?
1 EVERY DAY
2 SOME DAYS
3 NOT AT ALL GO TO SCEXIT3D
-1 DON’T KNOW GO TO SCEXIT3D
-2 REFUSED GO TO SCEXIT3D
[END CARI RECORDING IF CARICONSENT = 1]
ASK: Selected sample member meeting age, percent of time living in household, and military status eligibility
SCF9. INTERVIEWER: OBTAIN A GOOD PHONE NUMBER FOR THE SAMPLED ADULT.
So that my supervisor may check the quality of my work, can I have a telephone number they may call you back at?
PHONE NUMBER: ______________________________
[GO TO SCBEGIN]
ASK: Selected sample member meeting all eligibility requirements
SCEXIT1. Thank you for answering our questions, but I have the wrong address. Have a nice day/evening.
[EXIT SURVEY. DO NOT ASSIGN EVENT. KEEP AT MOST CURRENT STATUS/EVENT CODE.]
ASK: Screener reporting incorrect address.
SCEXIT1A. INTERVIEWER: TAP EXIT. THEN TAP MENU. EDIT ADDRESS AND MODIFY ADDRESS.
TAP MENU AGAIN TO UPDATE. RETURN TO SCREENING INSTRUMENT.
CHANGE ANSWER TO ‘YES, VERIFIED ADDRESS IS CORRECT’ AND PROCEED.
[DO NOT ASSIGN EVENT. KEEP AT MOST CURRENT STATUS/EVENT CODE.]
ASK: Screener reporting minor problems with address requiring edits
SCEXIT2. [EXIT/BREAKOFF] OBTAIN NAME, DATE, TIME TO RETURN
ASK: Screener reporting no adults are available at the time of screening
SCEXIT3. Thank you for answering our survey.
[IF NO ONE ELIGIBLE, FILL “IF ASKED, EXPLAIN THAT NO ONE WAS ELIGIBLE FOR THE STUDY.”]
[If SCBLANG=2, FILL “IF ASKED, EXPLAIN THAT we are only interviewing adults who speak English for the study.”]
[IF NO ONE age 18+, FILL “IF ASKED, EXPLAIN THAT we are only interviewing adults ages 18 and older for this study.” ]
[IF NO ONE age 25-54 FILL, “IF ASKED, EXPLAIN THAT we are only interviewing adults between the ages of 25 and 54 for this study.” ]
[If SCC8 = 2 (active military) FILL “IF ASKED EXPLAIN THAT we are only interviewing non-active service members for this study.” ]
[If SCC17 = 2 (part-time HH), FILL ”IF ASKED, EXPLAIN THAT we are only interviewing household members who are full-time residents for this study”. ]
[If NO SMOKERS, FILL “IF ASKED, EXPLAIN THAT we are only interviewing current cigarette smokers for this study.”]
[CONTINUE GO TO SCEXIT3END]
ASK: Respondents screened as ineligible
SCEXIT3C. May I please have [DISPLAYED NAME]’S phone number to schedule a time to return and complete the interview?
PHONE NUMBER: ______________________________
INTERVIEWER: LEAVE A “SORRY I MISSED YOU CARD” WITH YOUR PHONE NUMBER.
Thank you. Have a nice day/evening.
[EXIT SURVEY. SET SOFT CALLBACK - CODE 1293]
ASK: Screeners reporting selected adult is not available
SCEXIT3D. Thank you for answering our survey.
[IF SCF5<25 OR SCF5>54 OR SCF5A = -1 OR SCF5A = -2 OR SCF5A >4, FILL “IF ASKED, EXPLAIN THAT WE ARE ONLY INTERVIEWING ADULTS BETWEEN THE AGES OF 25 AND 54 FOR THIS STUDY.”]
[If SCF6 = 2 (active military) FILL “IF ASKED EXPLAIN THAT we are only interviewing non-active service members for this study.” ]
[If SCF7=2 (part-time HH), FILL “IF ASKED, EXPLAIN THAT we are only interviewing household members who are full-time residents for this study.” ]
[If NO SMOKERS, FILL “IF ASKED, EXPLAIN THAT we are only interviewing current cigarette smokers for this study.” ]
[if routed by checkbox 4, fill “IF aSKED, EXPLAIN THAT For this study, we are only interviewing current cigarette smokers between 25 and 54 who are full-time residents and not currently active service members.” ]
[If there is a secondary sampled adult, FILL “Unfortunately, you aren’t eligible for our study, so we will select another adult from your household,” return to SCF1 and FILL secondary sampled adult’s name. If no secondary household member, GO TO SCEXIT3END.]
ASK: Respondents screened as ineligible
So that my supervisor may check the quality of my work, please [IF NO ONE 25-54, FILL “give me”, IF NO ONE SELECTED, FILL “confirm”] your first and last name and telephone number.
FIRST AND LAST NAME: ____________________________ [SCEXIT3END_NAME]
PHONE NUMBER: ______________________________ [SCEXIT3END_PHONE]
Have a nice day/evening.
Have a nice day/evening. [EXIT SURVEY. ASSIGN PENDING REFUSAL CODE 1441 IF REFUSED TO SCREEN; ASSIGN FINAL SCREENING INELIGIBLE CODE 2601 IF INELIGIBLE – NO ONE 18+; ASSIGN FINAL SCREENING CODE 2605 IF INELIGIBLE – NO ELIGIBLE TOBACCO USERS SAMPLED]
ASK: Households screened as ineligible or refusing to provide information needed to determine eligibility
SCBEGIN At this time, I’d like to begin the survey by going over the types of questions you’ll be asked, as well as explaining any risks and benefits. But first, I will need a place to set up a laptop computer.
QUEXID: [QUEXID]
Name: [NAME OF SELECTED SAMPLE MEMBER]
Age: [AGE OF SELECTED SAMPLE MEMBER]
Phone: [PHONE OF SELECTED SAMPLE MEMBER]
[GO TO CHECK BOX 5]
ASK: Selected sample member meeting all eligibility requirements
OMB No. 0910-#### Expiration Date: ##/##/20##
Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 10 minutes per response to complete the survey questions. Send comments regarding this burden estimate or any other aspects of this information collection, including suggestions for reducing burden, to PRAStaff@fda.hhs.gov.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Gittleson, Daniel |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |