Parent Of Youth Baseline Survey Participants

Attachment 12_E2B: Telephone Verification Survey (ExPECTT II)

Form Approved

OMB No. 0910-0753

Exp. Date 09/30/2019

RIHSC No. 18-009CTP

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

Parent and Youth Verifications

ID:

INTRO1. Hello, my name is _______________________, with RTI International. May I speak with (YOUTH NAME/YOU (for 18+))?

1 = YES GO TO INTRO2a

2 = NO  GO TO Q1b

3 = UNKNOWN  INTRO6

INTRO2a. [IF Q1 = 1] I am calling to verify the work of one of our field representatives, (REPRESENTATIVE NAME), who reported conducting an interview with (YOUR CHILD/YOU (for 18+)) on (ADD DATE) for the Evaluation of the Public Education Campaign on Teen Tobacco. Do you remember (FILL: your child (for under 18)) completing the interview?

1 = YES GO TO Q2

2 = NO  GO TO CONCLUSION

ASK: All respondents

Q1b. [IF INTRO1 = 2] When would be a better time to speak with [FILL: PARENT NAME (for under 18) OR YOUTH NAME for 18+) or can (he/she) be reached at another number? (RECORD INFORMATION IN RECORD OF CALLS.)

1 = ANOTHER TIME GO TO CALLBACK

2 = ANOTHER NUMBER  GO TO ROSTER LINE

ASK: All respondents

Q1c. [IF INTRO1 = 3] Let me verify that I have dialed the correct number, that is [PHONE]

1 = YES GO TO CONCLUSION

2 = NO  EXIT CASE, AND REDIAL

ASK: All respondents

Q2. [IF INTRO2a = 1] First (FILL: were you (for 18+youth) was your child (for under 18 youth) interviewed in person?

1 = YES

2 = NO

ASK: All respondents

Q3. [IF INTRO2a = 1] 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

Q4. [IF INTRO2a = 1] Was the interview conducted in your home or somewhere else?

1 = IN RESPONDENT’S HOME

2 = SOMEWHERE ELSE (SPECIFY) ________________________________________

ASK: All respondents

Q4A. [IF INTRO2a = 1 AND UNDER 18] Were you given a printed copy of the parent permission form?

1 = YES

2 = NO

ASK: All respondents under 18

Q4B. [IF INTRO2a = 1 and UNDER 18] Was your child given a printed copy of the youth assent

form?

1 = YES

2 = NO

ASK: All respondents under 18

Q4C. . [IF INTRO2a = 1 and 18+] Were you given a printed copy of the consent

form?

1 = YES

2 = NO

ASK: All respondents 18+

Q5. [IF INTRO2a = 1] Was your child/you (for 18+) paid for their participation in the study?

1 = YES

2 = NO  SKIP TO Q8

ASK: All respondents

[IF Q5=1]

Q6. How much did they/you (for 18+) receive?

$ _______________

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

[IF Q5=1]

Q7. In what form were you (for 18+)/your child paid? [EXAMPLES: CASH, CHECK, MONEY ORDER]

INTERVIEWER: CODE RESPONSE INTO ONE OF THE FOLLOWING CATEGORIES:

1. CASH

2. CHECK

3. MONEY ORDER

4. OTHER

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

Q8. [IF INTRO2a = 1] Was your child/were you (for 18+), [FILL YOUTH NAME], interviewed?

1 = YES

2 = NO

ASK: All respondents

Q9. [IF INTRO2a = 1] Did your child/you (for 18+) enter some of the answers into the computer themselves?

1 = YES

2 = NO

ASK: All respondents.

SV8. [IF INTRO2a = 1] Did the interviewer behave in a professional manner?

1 = YES

2 = NO (PLEASE SPECIFY) __________________________________________________

ASK: All respondents.

Q11. [IFQ8 = 1 OR Q9 = 1 AND UNDER 18] Did [YFNAME YLNAME]’s interview take place on the same day as your interview or on a different day?

1 = SAME DAY

2 = DIFFERENT DAY

ASK: : Respondents that reported their child was interviewed (Q8 = 1) or reported their child entered some answers into the computer themselves (Q9 = 1) and is UNDER 18

Q12. [IFQ8 = 1 OR Q9 = 1] About how long did [YFNAME YLNAME’s/YOUR (for 18+)] interview take?

1 = <30 MINUTES

2 = 30-44 MINUTES

3 = 45-59 MINUTES

4 = 60-90 MINUTES

5 = OVER 90 MINUTES

ASK:

Respondents that reported their child was interviewed (Q8 = 1) or reported their child entered some answers into the computer themselves (Q9 = 1)

Q13. [IF INTRO2a = 1] 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

INTRO6 ( when CALL_IN = 4 - never heard of subject OR INTRO1 = 3 )

Let me make sure that I dialed the correct number. Is this ( <phone_display> )-<phone_display2>-<phone_display3> ?

1 = YES  GO TO CONCLUSION

2 = NO  GO TO WHO_REF

3 = LANGUAGE BARRIER  GO TO WHO_REF

4 = REFUSED GO TO WHO_REF

ASK: Respondents that call in and never heard of subject

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

ASK: All respondents

CALLBACK.

Thank you very much for your time, I will call back at a later time. Have a good (evening/day).

[SET FOR CALLBACK]

ASK: Respondents that will need to receive a call back

_________________________________________________________________________

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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