Form Approved
OMB No. 0910-0753
Exp. Date 01/31/2023
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:
CASH
CHECK
MONEY ORDER
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: 01/31/2023
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.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | PR* |
File Modified | 0000-00-00 |
File Created | 2022-04-08 |