0920-0621 NYTS Cognitive Testing Parent/ Guardian Screener

Form Approved

OMB No. 0920-0621

Exp. Date 01/31/2024

National Youth Tobacco Survey (NYTS)

Cognitive Testing Parent Recruitment Screener Questionnaire

Your child is invited to participate in an interview. The Centers for Disease Control and Prevention (CDC) has hired ICF to interview 40 youth. ICF is a company that conducts research. The purpose of the interviews is to help CDC test questions on health and tobacco product use. We will conduct 40 interviews with youth in [INSERT DATE]. Each interview will last about 2 hours. If your child participates the interview, they will receive a $50 Amazon gift card in appreciation of their time.

This survey will be used to identify eligible participants for the interviews. This survey should take about 10 minutes to complete. Your responses to the survey are private. This survey involves no known risks. There is no penalty for not doing the interview. You can skip questions you don’t want to answer or end the survey at any time.

If you agree to participate in this survey select “yes, I agree” below.

01 Yes, I agree

02 No, I do not agree [TERMINATE]

If you have any questions about the survey or this study, email ICF’s Research Manager, Rachel Kinder, at cdcnyts@icfsurvey.com. For questions regarding your rights related to this evaluation you can contact ICF’s Institutional Review Board (IRB) at IRB@icf.com.

CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0621).

//Ask All//

INTRO2. To determine your child’s eligibility to participate in an interview, please complete the following questions. If you have more than one child up to age 18, please think about the child with the next birthday.

//Ask All//

CHILD. Are you the parent or legal guardian of the child who would be participating in the interview?

01 Yes

02 No [TERMINATE]

//Ask All//

AGE. How old is your child?

[NUMBER BOX] [RANGE 0-18] [TERMINATE IF AGE=0-10]

//Ask All//

GRADE. What is your child’s grade level in school?

01 6^th grade

02 7^th grade

03 8^th grade

04 9^th grade

05 10^th grade

06 11^th grade

07 12^th grade

08 Other, please specify: [TEXT BOX]

97 Prefer not to answer [TERMINATE]

//Ask All//

RACE. Which of the following best represents your child’s race/ethnicity? Please select all that apply.

01 American Indian or Alaskan Native

02 Asian

03 Black or African American

04 Hispanic

05 Native Hawaiian or Pacific Islander

06 White

07 Some other race or ethnicity: [TEXT BOX]

//Ask All//

SEX. What sex was your child assigned at birth, on their original birth certificate?

01 Male

02 Female

//Ask All//

INCOME. What is your annual household income?

01 Less than $10,000

02. $10,000 to $29,000

03 $30,000 to $39,000

04 $40,000 to $49,000

05 $50,000 to $99,000

06 $100,000 or above

Does your child receive free or reduced lunch in schools?

01 Yes

02 No

//Ask All//

Tobacco use: Does your child use any tobacco products?

01 Yes

02 No

03 Don’t know

Do any of your child’s friends use tobacco products?

01 Yes

02 No

03 Don’t know

How familiar is your child with tobacco products like cigarettes, e-cigarettes, or vape pens?

1. Very familiar

2. Somewhat familiar

3. Unfamiliar

4. Don’t know

//Ask All//

Geographic location: Where do you live? ¹

1. City: ____________________________

2. State: [selected from drop down list]

//Ask All//

CONTACT. Please provide your contact information below so that we can reach out to schedule the interview, if your child is selected to participate.

Parent / Guardian’s Full Name: [TEXT BOX]

Child’s Full Name: [TEXT BOX]

Parent / Guardian’s Phone Number: [NUMBER BOX]

Parent / Guardian’s Email Address: [EMAIL TEXT BOX]

//Ask All//

CLOSE. Thank you for completing this questionnaire. If your child is selected to participate, we will reach out to you shortly to gather a little more information and schedule a time for the interview.

1 We will use the Robert Wood Johnson Foundation’s County Health Rankings to understand participant’s surrounding community.