0920-0621 NYTS Cognitive Testing Youth Screener

Form Approved

OMB No. 0920-0621

Exp. Date 01/31/2024

National Youth Tobacco Survey (NYTS)

Cognitive Testing Youth Recruitment Screener Questionnaire

Thank your interest in this study! Answer the following questions to see if you quality for an interview. The questions should take 5-10 minutes to answer. Your answers are private.

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 the CDC test questions on health and tobacco product use. If you are selected to participate you will receive a $50 Amazon gift card for participating in the interview.

Completing this survey involves no known risks. Your participation in the survey and interview are voluntary. There is no penalty for not participating. You can skip questions you don’t want to answer. You can end the survey or interview at any time. However, you will not qualify for an interview if you do not complete the survey. Completing this survey does not guarantee that you will be invited to an interview.

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. Please complete the following questions. The research will help improve survey questions that go to thousands of youths across the United States. Topics include health behaviors, attitudes of youth, and tobacco (including e-cigarette) use.

The interview will be conducted through Microsoft Teams at a time that is convenient to you. You will be asked to answer survey questions during the interview, and the interviewer will ask you questions about how you answered the survey questions.

//Ask All//

ETHN. Are you Hispanic, or Latino?

1. Yes, Hispanic or Latino

2. No, not Hispanic or Latino

//Ask All//

RACE. What race or races do you consider yourself to be? (Please select all that apply)

01 American Indian or Alaskan Native

02 Asian

03 Black or African American

05 Native Hawaiian or Pacific Islander

06 White

07 Some other race or ethnicity: [TEXT BOX]

//Ask All//

Geographic location: Where do you live? ¹

1. City: ____________________________

2. State: [selected from drop down list]

//Ask All//

ENVI. Thinking about your neighborhood, how would you compare how safe you feel in your neighborhood compared to other people?

01 A lot safer

02 A little safer

03 About the same

05 A little less safe

06 A lot less safe

//Ask All//

SO. Which of the following best describes you?

01 Straight (that is, not gay)

02 Lesbian

03 Gay

04 Bisexual

05 Some other sexual orientation: [TEXT BOX]

//Ask All//

GI. Some people describe themselves as transgender when their sex at birth does not match the way they think or feel about their gender. Are you transgender?

01 No, I am not transgender

02 Yes, I am transgender

03 I am not sure if I am transgender

04 I do not know what this question is asking

//Ask All//

SOCIAL. Which of the following social media do you use? (Please select all that apply)

01 Facebook

02 Twitter

03 YouTube

04 Instagram

05 Reddit

06 TikTok

07 Snapchat

08 Twitch

09 Other (please specify): ______[SMALL TEXTBOX]________

10 None [exclusive response]

//Ask All//

USE1. Have you ever tried any of the following? (Please select all that apply.)

1. E-cigarettes, vapes, or vape pens

2. Heated tobacco products

3. Cigarettes

4. Cigars

5. Marijuana cigars (blunts)

6. Hookah

7. Roll-your-own cigarettes

8. Pipe tobacco

9. Bidis

10. Chewing tobacco, snuff, or dip

11. Snus

12. Nicotine pouches

13. Other oral nicotine products (including dissolvable tobacco products)

14. I have not tried any of these products [exclusive response]

//IF USE1 = 01-13//

USE2. During the past 30 days, have you used any of the following? (Please select all that apply.)

1. E-cigarettes, vapes, or vape pens

2. Heated tobacco products

3. Cigarettes, even one or two puffs

4. Cigars

5. Marijuana cigars (blunts)

6. Hookah

7. Roll-your-own cigarettes

8. Pipe tobacco

9. Bidis

10. Chewing tobacco, snuff, or dip

11. Snus

12. Nicotine pouches

13. Other oral nicotine products (including dissolvable tobacco products)

14. None, I no longer use tobacco products [exclusive response]

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