Attachment B - Screener

OMB Control #0910-0810
Exp. Date: 10/31/2021

Hookah Purchase Journey: Online Hookah User Survey

SCREENER
Screener
S1. How old are you? (SELECT ONE)
1.
2.
3.
4.
5.
6.
7.

Under 18 [TERMINATE]
18-24
25-34
35-44
45-54
55-64
65+

S2. Please indicate your gender. (SELECT ONE)
1.
2.

Male
Female

S3. From the drop-down list provided, please select the state in which you live. [INSERT U.S. DROP-DOWN LIST.
RESPONDENT MUST LIVE IN THE U.S. SEND-OUT: U.S. CENSUS REPRESENTATIVE. NO QUOTAS ON
RETURNS.]. (SELECT ONE)
S4. We are interested in talking with people about their smoking habits. Which of the following, have you smoked
in the last 12 months? (SELECT ALL THAT APPLY)
1.
2.
3.
4.
5.
6.

Cigars
E-cigarettes
Regular cigarettes
Hookah [MUST BE SELECTED TO CONTINUE]
Pipe
Other

S5. You indicated that you have smoked hookah in the last 12 months. Have you smoked hookah…? [YES/NO FOR
EACH]
1.
2.

In your home or someone else’s home in the last 12 months [IF SELECTED, ASK QUESTIONS FOR INHOME USE. CREATE HIDDEN PUNCH.]
At a hookah lounge, bar, or restaurant in the last 12 months [IF SELECTED, ASK QUESTIONS FOR ONPREMISE USE. CREATE HIDDEN PUNCH.]

S6. Have you, yourself, purchased any hookah tobacco or herbal (non-tobacco) shisha in the last 12 months?
1.
2.

Yes [MUST BE SELECTED TO CONTINUE]
No [TERMINATE]

Paperwork Reduction Act Statement: The public reporting burden for this information collection
has been estimated to average 3 minutes per response to complete the screener (the time
estimated to read and complete). Send comments regarding this burden estimate or any other
aspects of this information collection, including suggestions for reducing burden, to
PRAStaff@fda.hhs.gov.

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