Form 0920-1083 Screening and Consent

Study Information
Client: RTI
Project Title: Tips 10 Wave 1
Ipsos Job Number: 20-010771-01
Account Executive: Michael Lawrence (michael.lawrence@ipsos.com)
Project Manager: Poom Nukulkij (poom.nukulkij@ipsos.com)
Research Associate:
Sample Variables
•
•
•
•
•
•
•
•
•
•
•

KP standard demographics
XACSLANG
XSPANISH
XSMOKE
XDMA (DMA)
XG9 (W1 G9 answer; 1-9)
XG20 (W1 G20 answer; 1-9)
XG21 (W1 G21 answer; 1-9)
XW1SMOKE (Original Smoking Status)
xABSMNO_a
XIND1

Quota Description
No quotas.
Standard Question Type Descriptions
Standard question types include:
• S=Single Select: Allows respondents to select one answer in a list of options.
• M=Multi-select: Allows respondents to select multiple answers from a list of options.
• DD=Dropdown Menu: Allows respondents to select one answer from a drop-down menu of
options.
• Grid (including options for banked or accordion grids)
• S (Optional: Banked/Accordion) Grid: Allows respondents to select one answer in a 2dimensional grid layout.
• M (Optional: Banked/Accordion) Grid: Allows respondents to select multiple answers in a 2dimensional grid layout.
• N=Number: Allows respondents to enter a numeric response in an open-ended answer field
(specify valid range or number of digits, e.g., up to three digits for age, five numbers for zip code)
• T=Text: Allows respondents to enter a text response in an open-ended answer field (specify size
as Small, Medium, Large or a specific number of characters, e.g., two letters for U.S. state)
• DISP=Display/Descriptive Content: Displays text and/or multimedia elements to respondents
without requiring interaction.
• RT=Ratings Thermometer: Allows respondents to select a numeric value (usually 0-100 on a
visual scale resembling a thermometer
• RS=Ratings Slider: Allows respondents to select a numeric value (usually 0-100 on a horizontal
visual scale with the endpoints labelled

Main Questionnaire (including screener, if applicable)
Programming Notes:
• Code all refusals as -1.
• Use default instruction text for each question type unless otherwise specified.
• Do not prompt on all questions.
Scripter: For testing only, show this initial screen to determine sample type:

BASE: All respondents
MNO_TEST [N with range 0 to 3000000000]
Enter member number for testing:
KP (OFFPANEL=0): 0-1000000000
ABS (OFFPANEL=1): 1000000001 to 3000000000
BASE: If R is completing on a mobile phone or tablet
TakePC [S; prompt once]
To make sure you can view all the multimedia elements in this survey, we would like you to
complete this survey on a laptop or desktop PC or Mac, if possible.
Do you have access to a laptop or desktop PC or Mac?
1. Yes
2. No
Scripter: Autofill TakePC=2 if R refuses after prompt.

BASE: If TakePC=1
HAS_PC [DISP]
Please exit this window and log on to your laptop, desktop PC, or Mac.
You can return to this survey on your computer by clicking the link in the email invitation you
received for this survey. When you re-enter the survey, it will restart where you left off.
BASE: If TakePC=2
NO_PC [DISP]
Even though you don't have access to a laptop or desktop PC or Mac, we'd still like you to
complete this survey.
Please press the "Next" button below to continue.
SCREENING QUESTIONNAIRE
Scripter: Suppress PREFER_LANG and auto-punch English until Spanish translation is prepared

BASE: All respondents
Prefer_Lang [S; prompt once]
¿Prefiere llenar sus encuestas en inglés o en español?

Do you prefer to do surveys in English or Spanish?
1. English
2. Español
Scripter:
If PREFER_LANG = "Español", show Spanish version of the survey.
If PREFER_LANG = "English" or refused, show English version of the survey.
Use sample variable XW1SMOKE for KP values and XW1SMOKE from lookup table for ABS values.
If XW1SMOKE=4 ‘Fresh’ or missing DOV_RECONTACT=2 (fresh). Else DOV_RECONTACT=1
(recontact).
Scripter: The Privacy Policy text below should link to
https://cdn.ipsosinteractive.com/projects/S19016223/TIPS_ABS_Privacy_Policy.html

BASE: If OFFPANEL=1
COOKIES [S; prompt once]
Thank you for your interest in the CDC Summer 2020 Health Issues Survey!
By taking this survey, you agree to our Privacy Policy and use of cookies.
[If DOV_RECONTACT=1] As someone who has completed one or more previous CDC Health
Issues surveys, your survey experience will remain unchanged from before if you accept.
1. Accept and continue to the survey
2. No, thank you
Scripter: Terminate if COOKIES=2 or refused after prompt.

SCREENER FOR FRESH CASES
BASE: If DOV_RECONTACT=2
OMB_FRESH_ABS [DISP]
Form Approved
OMB No. 0920-1083
Exp. Date 3/31/2023
Extended Evaluation of the National Tobacco Prevention and Control Public Education
Screening Questionnaire
Public reporting burden of this collection of information is estimated to average 5 minutes per
response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data 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 Reports Clearance Officer, 1600
Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1083).

BASE: If OFFPANEL=0 and DOV_RECONTACT=2
KP_S1 [DISP]
Welcome to the Summer 2020 CDC Health Survey! Your opinion counts!
Please try to answer all questions to the best of your ability. Your answers will be kept private.
We have a few qualifying questions about you and other members of your household.
If you are selected and complete our one-time 30 minute interview, you'll receive a minimum of
15,000 bonus points credited to your KnowledgePanel account depending on your qualification
status as our way of saying “thank you.”
BASE: If OFFPANEL=1 and XW1SMOKE=4 or 9
ABS_S1 [S; prompt once]
Welcome to the Summer 2020 CDC Health Survey! Your opinion counts!
Please try to answer all questions to the best of your ability. Your answers will be kept private.
We have a few qualifying questions about you and other members of your household.
If you are selected and complete our one-time 30-minute interview, you'll be sent $20 as our
way of saying “thank you.”
First, are you currently 18 years old or older?
1. Yes
2. No
Scripter: Terminate if ABS_S1 refused after prompt.

BASE: If ABS_S1=2
ABS_S1a. [S]
In order to complete the questions to determine eligibility for your household, you must be at
least 18 years old. Would you please have someone in your household who is 18 or older log on
to complete the screening for the project? They can use the same login information and
password as you have used to access the survey or just click the "Next" button to return to the
beginning of the survey. Thank you!
Scripter: Return to PREFER_LANG up to two times. Terminate if ABS_S1A is shown three times with no
response.

BASE: If DOV_RECONTACT=2
ALL_S2 [S; prompt once]
Including yourself, how many adults 18 or older are currently living in your household?
1. 1
2. 2
3. 3
4. 4
5. 5 or more

6. None, no adults live here
Scripter: Terminate if ALL_S2=6 (None, no adults live here) or refused after prompt.

BASE: If DOV_RECONTACT=2
ALL_S4 [Grid, S across]
Next, we’d like some brief information about you [IF ALL_S2=2-5: and each of the other adults
in the household]. [INSERT IF ALL_S2=2-5: For each adult including yourself, please answer
the following questions.]
Scripter: Populate as many rows as number of adults indicated at ALL_S2, with maximum of 5. Prompt up
to two times if any cell refused.
1. For Age, show number boxes with range 18-99; do not show range in instruction text.
2. For "Sex", show "Male" and "Female" responses.
3. For "Smoke at least 100 cigarettes?", show "Yes" and "No" responses.

ALL_4A. [IF ALL_S2=2-5:
How old is each person
below?
(in years) / [IF
ALL_S2=1: HOW OLD ARE
YOU (IN YEARS)?]

You
Adult 2
Adult 3
Adult 4
Adult 5

ALL_4B. What sex
was [IF ALL_S2=2-5:
this person/ IF
ALL_S2=1: you]
assigned at birth, on
was [IF ALL_S2=2-5
their/ IF ALL_S2=1:
your] original birth
certificate?
O Male O Female
ODon’t know O Refused
O Male O Female
ODon’t know O Refused
O Male O Female
ODon’t know O Refused
O Male O Female
ODon’t know O Refused
O Male O Female
ODon’t know O Refused

ALL_4C. [IF ALL_S2=25: Has this person
smoked at least 100
cigarettes in his/her
life? / IF ALL_S2=1: Have
you smoked at least
100 cigarettes in your
lifetime?]
O Yes O No
O Yes O No
O Yes O No
O Yes O No
O Yes O No

Scripter: Terminate if any field in ALL_S4 refused after two prompts.

BASE: If DOV_RECONTACT=2
Scripter: Show ALL_S5 for each adult smoker entered in ALL_S4, with smoking defined as "Yes" to
having smoked 100 cigarettes in lifetime. Populate the dynamic age and gender text for each adult based
on information from the ALL_S4 table.

ALL_S5. [GRID; S across; prompt twice]
[IF ALL_S2=1: Do you / IF ALL_S2=2-5: For each person who smoked 100 or more cigarettes in
his or her lifetime, does he or she] now SMOKE EVERY DAY, SOME DAYS, OR NOT AT ALL?
1. Every day

2. Some days
3. Not at all
Scripter: List each person who smoked 100 or more cigarettes (ALL_4c=Yes) by ‘X year old’
‘male/female’ for each row.

Every day

Some days

Not at all

Scripter: Terminate if any All_S5 is refused after two prompts.
Data-only variable classification of smoking status for each adult in the household, starting with the initial
respondent first:
Assign DOV_SURVEY_1R to DOV_SURVEY_XR where numeric value X corresponds with household
roster position:
X=1: Initial respondent (Adult 1)
X=2: Adult 2
X=3: Adult 3
X=4: Adult 4
X=5: Adult 5
1. Current Smoker – ALL_S5=1 (every day) or ALL_S5=2 (some days)
2. Former Smoker – ALL_S5=3 (not at all)
3. Never Smoker – ALL_4C=2 (no)
DOV_HOUSE_SMOKE – Classification of household smoking status:
1. Fully smoking household – All adults are current smokers
2. Partial smoking household – At least one adult is a current smoker but not all adults smoke
3. Non-smoking household – No adult is a current smoker

ELIGIBILITY DECISION POINT FOR KP
For all fresh KP respondents (OFFPANEL=0), DOV_SURVEY_1R is always 1 (initial respondent).
If OFFPANEL=0 and DOV_RECONTACT=2, allow respondents to continue or terminate using the criteria
below:
1. If XW1SMOKE=1 and ALL_4C=1 and (ALL_S5=1 or 2), allow 100% of eligible respondents to continue
and go to ABS_G20
2. If XW1SMOKE=2 and ALL_4C=1 and (ALL_S5=1 or 2), allow 100% of eligible respondents to continue
and go to ABS_G20
3. If XW1SMOKE=3 and ALL_4C=1 and (ALL_S5=1 or 2), allow 100% of eligible respondents to continue
and go to ABS_G20
4. If XW1SMOKE=4 and ALL_4C=1 and (ALL_S5=1 or 2) (initial respondent is a smoker), allow 100% of
eligible respondents to continue and go to ABS_G20
5. If XW1SMOKE=1-4 or 9 (missing) and ALL_4C=2 or (ALL_4C=1 and ALL_S5=3) (initial respondent is
a nonsmoker), terminate

ELIGIBILITY DECISION POINT FOR ABS
If OFFPANEL=1, select a respondent using the criteria below:
Select FULLY SMOKING HOUSEHOLDS (all adults smoke) with certainty (at 100%).

1. Allow 100% of eligible respondents to continue.
2. If only one adult smoker, elect that smoker with certainty and continue to ABS_S6.
3. If more than one adult smoker in a smoker household, randomly select one smoker to interview.
4. If DOV_SURVEY_1R=1 (initial informant is selected), continue to ABS_S6.
5. If other household member is selected (DOV_SURVEY_2R to DOV_SURVEY_5R=1), continue to
ABS_S7.
6. Do not select any non-smokers here.
Select PARTIAL SMOKING HOUSEHOLDS (at least one adult is a current smoker, but not all adults
smoke) with certainty (at 100%):
1. Allow 100% of eligible respondents to continue.
2. All partial smoking households will have at least one smoker and one nonsmoker.
3. Use weighted selection in these households, selecting an adult nonsmoker 0% of the time and an adult
smoker 100% of the time. In other words only smokers should be selected at this stage.
4. If more than one smoker in the household, randomly select one smoker to interview.
5. If initial informant is selected (DOV_SURVEY_1R=1), continue to ABS_S6.
6. If other household member is selected (DOV_SURVEY_2R TO DOV_SURVEY_5R=1), CONTINUE
TO ABS_S7.
For NONSMOKER HOUSEHOLDS (no adult smokers in household), select 0% of nonsmoker
households. Terminate and go to ABS_END for those not selected. Create DOV indicating whether
household was selected.
1. At the start, allow 100% of eligible respondents to continue.
2. If only one adult nonsmoker, select that nonsmoker.
3. If more than one adult nonsmoker in the nonsmoker household, randomly select one nonsmoker to
interview.
4. If initial informant is selected, (DOV_SURVEY_1R=1), continue to ABS_S6.
5. If other household member is selected (DOV_SURVEY_2R TO DOV_SURVEY_5R=1), continue to
ABS_S7.
For QC, show DOV screen for which respondent is selected
Create DOV_SURVEY_1R and fill with roster position of selected respondent:
1=INITIAL RESPONDENT (ADULT 1)
2=ADULT 2
3=ADULT 3
4=ADULT 4
5=ADULT 5
Scripter: If DOV SURVEY_1R=1 and DOV_RECONTACT=2 program DOV_T10W1_SMOKE per
specifications:
DOV_T10W1_SMOKE=3 (nonsmoker): If ALL_4C for selected respondent=2
DOV_T10W1_SMOKE=2 (former smoker): If ALL_4C for selected respondent=1 and ALL_S5=3
DOV_T10W1_SMOKE=1 (smoker): If ALL4C for selected respondent=1 and (ALL_S5=1 or 2)

BASE: Display for ineligible households
ABS END. [DISP]
Thank you for your participation today. Your answers to this short survey were very valuable to
us, as of this time, all the longer surveys you could participate in have been completed for us so
you have not been selected for our study.

Thanks again for your contribution to this important research.
Scripter: Terminate after showing ABS_END.

BASE: If initial informant ADULT1 is selected (DOV_SURVEY_1R=1) and household is selected
per eligibility decision point
ABS_S6. [DISP]
Good news! You have been selected for our study, which takes about 30 minutes to complete
for a $20 or higher reward, depending on your qualification status.
BASE: If other adult ADULT2-5 is selected (DOV_SURVEY_1R=2 to 5) and household is
selected per eligibility decision point
ABS_S7. [DISP]
Good news! The [gender and age for selected respondent based on SURVEY_1R: age year old
male/female] in your household has been selected for our study and can earn $20 or more for
completing the longer questionnaire.
Would you please ask [gender for selected respondent based on SURVEY_1R: him/her] to
come to the computer to complete the rest of the survey, starting with the next screen?
If [gender for selected respondent based on SURVEY_1R: he/she] is not available now, [gender
for selected respondent based on SURVEY_1R: he/she] can log back into the survey and
continue it from this point, using the same login information and password as you have used to
access the survey.
Thank you!
BASE: If DOV_SURVEY_1R=2 to 5 (other adult is selected)
Scripter: Suppress this question and auto-punch English until Spanish translation is prepared

PREFER_LANG2 [S; prompt once]
¿Prefiere llenar sus encuestas en inglés o en español?
Do you prefer to do surveys in English or Spanish?
1. English
2. Español
Scripter:
If PREFER_LANG2 is "Español", show Spanish version of the remainder of the survey.
If PREFER_LANG2 is "English" or refused, show English version of the remainder of the survey.

BASE: If DOV_SURVEY_1R=2 to 5 (other adult is selected)
ABS_AGE1 [Q, Range 0-99; prompt once]
How old are you?
_____ years old
Scripter: Terminate if ABS_AGE1 does not match age of selected respondent (ALL_4A).

BASE: If DOV_SURVEY_1R=2 to 5 (other adult is selected)
ABS_GEND1 [S; prompt once]
What sex were you assigned at birth, on your original birth certificate?
1. Male
2. Female
3. Refused
4. Don’t know
BASE: If DOV_SURVEY_1R=2 to 5 (other adult is selected)
ABS_S3c [S; prompt once]
Have you smoked at least 100 cigarettes in your entire lifetime?
1. Yes
2. No
Scripter: Terminate if ABS_S3c is refused after prompt.

BASE: If ABS_S3C=1
ABS_S3d [S; prompt once]
Do you now smoke every day, some days, or not at all?
1. Every day
2. Some days
3. Not at all
Scripter: Terminate if refused after prompt.
If alternate respondent selected (DOV_SURVEY_1R NE 1), update smoker status DOV_T10W1_SMOKE
for selected respondent based on responses to ABS_S3C AND ABS_S3D:
1. CURRENT SMOKER – ABS_S3D=1 or 2
2. FORMER SMOKER – ABS_S3D=3
3. NEVER SMOKED – ABS_S3C=2

BASE: If DOV_RECONTACT=2
ABS_G20 [S; prompt once]
Do you or anyone else in your household connect to the Internet from your home?
1. Yes
2. No
BASE: If ABS_G20=1 and DOV_RECONTACT=2
ALL_G20a [S]
What type of Internet connection do you most often use at home to connect to the Internet? Is
it…?
1. Dial-up connection through the telephone
2. Wired with a high speed connection (cable, fiber optic, satellite, DSL, etc.)

3. Wireless connection with a desktop computer, laptop, or tablet
4. Wireless connection with a cell phone or smart phone
5. Not at all sure
6. I personally cannot access the Internet at home
BASE: If DOV_RECONTACT=2
ALL_G20b [S]
What type of Internet connection are you currently using to take this survey?
1. Dial-up connection through the telephone
2. Wired with a high speed connection (cable, fiber optic, satellite, DSL, etc.)
3. Wireless connection with a desktop computer, laptop, or tablet
4. Wireless connection with a cell phone or smart phone
5. Not at all sure
BASE: If DOV_RECONTACT=2
INTRODUCTION. [DISP]
You qualify to participate in a survey that will take about 20-30 minutes to complete. You will be
asked various questions about your experiences with tobacco and television ads about smoking
as well as a few questions about your background. The goal of this survey, which will include
approximately 10,000 individuals nationwide, is to provide more in-depth analysis of mass
media efforts and reactions to television ads.
Your responses will be maintained in a secure manner and no personal identification
information will be passed on to the sponsors of this study. In addition, your name or other
personal information will never be associated with your responses. The data collected for this
research study will be combined with that of all participants before it is analyzed.
If you choose to participate in this survey, you will be contacted to participate in a series of
follow-up surveys on a quarterly basis. The first follow-up survey will occur in approximately 3
months. The additional surveys will take about the same amount of time to complete.
There are no physical risks involved in participating in this study; however, it is possible that you
could find some of the questions to be sensitive. If you find a question during the survey to be
too personal, you may choose not to answer the question. Your participation is strictly voluntary
and you may terminate your participation at any time. The benefit of participating in this study is
to assist the sponsor in determining a nationwide estimate of awareness of an important media
campaign. If you are qualified, [IF OFFPANEL=0: you will be awarded 15,000 bonus points
credited to your KnowledgePanel account for completing the survey.] [IF OFFPANEL=1 and
ABS_G20=1 or refused: you will receive a check for $20 for completing the survey. / IF
OFFPANEL=1 and ABS_G20=2: you will receive a check for $40 for completing the survey.]
This survey is being conducted on behalf of the Centers for Disease Control and Prevention
(www.cdc.gov) and RTI International (www.rti.org), a non-profit research organization that
conducts studies on many types of health and social issues. [IF OFFPANEL=0: If you have any
questions about this study, you can contact KnowledgePanel Panel Relations at 1-800-7826899 and you will be directed to the appropriate researchers.] If you have any questions about
your rights as a study participant, you can contact RTI’s Human Research Protections Office by
email at orpe@rti.org, or by phone at 1-866-214-2043 (a toll-free number). Please print or save
a copy of this document for your records.

BASE: If DOV_RECONTACT=2
ALL_CONSENT [S; prompt once]
I have read and understand the information provided above and the study purpose and
procedures are clear to me.
1. Yes, I agree to participate in this study.
2. No, I do not wish to participate in this study.
Scripter: Terminate if ALL_CONSENT ="No" or refused after prompt.

BASE: If ALL_CONSENT=2 or refused
NOT_QUALIFIED [DISP]
Thank you for your participation. For this portion of the survey, either you do not qualify or we
have received all the responses we require.
BASE: If DOV_RECONTACT=2
ALL_DISP1 [DISP]
Our first few questions are primarily for classification purposes and they enable us to select the
questions to ask you later in the survey. They will also help us properly analyze responses to
this survey.
BASE: If OFFPANEL=1
ABS_G12 [DROPDOWN]
In which state do you live?
_________Pull Down List of States
Scripter: For ABS sample, populate PPSTATEN with corresponding value from ABS_G12

BASE: If DOV_RECONTACT=2
ALL_G14_FRESH [Q, Range 00000-99999; prompt once]
In what zip code do you live?
Scripter: Terminate if ALL_G14 refused after prompt.

BASE: If DOV_RECONTACT=2
ALL_G14a_FRESH [S; prompt once]
You told us you live in zip code [SHOW ZIP CODE FROM ALL_G14_FRESH].
Is this correct?
1. Yes
2. No
Scripter: If ALL_G14a_FRESH=“No” or refused after prompt, show ALL_G14_FRESH again. Record
most current zip code entered.
Variable name: QMSACAT
Type: S

Response list:
1. Yes
2. No
Use crosswalk table based on zip_level_table.xlsx
Update this variable if new zip is entered if looped back
Record DOV_DMA based on zip code entered using stat_dma lookup table
For ABS sample, recode ALL_4A and ALL_4B values for the selected respondent into PPAGE and
PPGENDER

BASE: If OFFPANEL=1 and DOV_RECONTACT=2
ABS_NQRACE1_FRESH [S]
Are you Hispanic or Latino?
1. Hispanic or Latino
2. Not Hispanic or Latino
BASE: If OFFPANEL=1 and DOV_RECONTACT=2
ABS_NQRACE2_FRESH [M]
What is your race?
American Indian or Alaska Native – Type in name of enrolled or principal tribe [O]
Asian
Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian – Type in race [O]
Black or African American
Native Hawaiian or Other Pacific Islander
Guamanian or Chamorro
Samoan
Other Pacific Islander – Type in race [O]
White
Create data-only variable PPETHM by using the below logic involving responses to QRACE1 and
QRACE2
Variable name: PPETHM
Type: S
Variable Text: Census Ethnicity demographic
Response list:
1. White, Non-Hispanic
2. Black, Non-Hispanic
3. Other, Non-Hispanic

4. Hispanic
5. 2+ Races, Non-Hispanic
Compute Asian=0.
Compute nhopi=0.
If qrace2_4=1 or qrace2_5=1 or qrace2_6=1 or qrace2_7=1 or qrace2_8=1 or qrace2_9=1 or
qrace2_10=1 asian=1.
If qrace2_11=1 or qrace2_12=1 or qrace2_13=1 or qrace2_14=1 nhopi=1.
Count numraces=qrace2_1 qrace2_2 qrace2_3 asian nhopi qrace2_15 (1).

ABS_NQRACE1_FRESH

ABS_NQRACE2_FRESH.

PPETHM

1 1 and numraces=1

1

1 2 and numraces=1

2

3 OR 4 OR 5 OR 6 OR 7
OR 8 OR 9 OR 10 OR 11
1
OR 12 OR 13 OR 14 OR
15 and numraces=1

3

1 numraces > 1

5

2 OR 3 OR 4 OR 8

1 OR 2 OR 3 OR 4 OR 5
OR 6 OR 7 OR 8 OR 9
OR 10 OR 11 OR 12 OR
13 OR 14 OR 15
(numraces=1 or
numraces>1)

REFUSED

Any value

MISSING

Any value

REFUSED

MISSING

2 OR 3 OR 4 OR 8

REFUSED

4

4

BASE: If ((DOV_RECONTACT=2 and (XACSLANG=4 or missing)) and PPETHM=4) or
(DOV_RECONTACT=2 and PPETHM=4 and TEST SAMPLE=ABS)
QACSLAN1 [S]
Do you speak a language other than English at home?
1. Yes
2. No
BASE: If (DOV_RECONTACT=2 and (XACSLANG=4 or missing) and QACSLAN1=1) or (TEST
SAMPLE=ABS and QACSLAN1=1)
QACSLAN2 [S]
What language do you speak at home other than English?
1. Spanish

2. Chinese (any dialect)
3. Tagalog
4. Vietnamese
5. French
6. German
7. Another language
BASE: If (DOV_RECONTACT=2 and (XACSLANG=4 or missing) and QACSLAN1=1) or (TEST
SAMPLE=ABS and QACSLAN1=1)
QACSLAN3 [S]
How well do you speak English?
1. Very well
2. Well
3. Not well
4. Not at all
Create Data-only variable QACSLANG by using the below logic involving responses to QACSLAN1QACSLAN3
create numeric variable, qacslang, range [1,3]
if qacslan1=2 qacslang=1.
if qacslan1=REFUSED and (respondent is taking survey in English – survey language is based on
Prefer_Lang2 if adult 2-5 is seletcted, else based on Prefer_Lang) qacslang=1.
if qacslan1=REFUSED and (respondent is taking survey in Spanish – survey language is based on
Prefer_Lang2 if adult 2-5 is seletcted, else based on Prefer_Lang) qacslang=3.
if qacslan2=2-7, REFUSED and (respondent is taking survey in English – survey language is based on
Prefer_Lang2 if adult 2-5 is seletcted, else based on Prefer_Lang) qacslang=1.
if qacslan2=2-7, REFUSED and (respondent is taking survey in Spanish – survey language is based on
Prefer_Lang2 if adult 2-5 is seletcted, else based on Prefer_Lang) qacslang=3.
if qacslan2=1 and (qacslan3 =1 or qacslan3=2) qacslang=2.
if qacslan2=1 and (qacslan3 =3 or qacslan3=4) qacslang=3.
if qacslan2=1 and (qacslan3=REFUSED) and (respondent is taking survey in English – survey language
is based on Prefer_Lang2 if adult 2-5 is seletcted, else based on Prefer_Lang) qacslang=2.
if qacslan2=1 and (qacslan3=REFUSED) and (respondent is taking survey in Spanish – survey language
is based on Prefer_Lang2 if adult 2-5 is seletcted, else based on Prefer_Lang) qacslang=3.
DATA ONLY [SINGLE PUNCH]
DOV_ACSLANG – LANGUAGE PROFICIENCY - AGGREGATE OF XACSLANG AND QACSLANG
(QACSLAN1-QACSLAN4)
Instructions: IF XACSLANG=1-3 THEN DOV_ACSLANG=XACSLANG. IF XACSLANG=4 OR NULL
THEN DOV_ACSLANG=QACSLANG. IF XACSLANG=5 THEN DOV_ACSLANG=5.
1. English Proficient
2. Bilingual
3. Spanish Proficient
4. Hispanics who have missing data; re-ask in field
5. Non-Hispanics, not asked
SAMVAR Definition
Variable name: XACSLANG
Type: SP
Variable Text: Primary Language
Response list:
1. English Proficient

2. Bilingual
3. Spanish Proficient
4. Hispanics who have missing data; re-ask in field
5. Non-Hispanics, not asked
________________________________________
Scripter: [If selected R is a current smoker (ALL_S5=1 or 2 if initial respondent is selected or ABS_S3D=1
or 2 if another household member is selected), go to Smoker survey]
[If selected R is a former smoker ((ALL_4C=Yes and ALL_S5="Not at all" if initial respondent is selected)
or (ABS_S3C=Yes and ABS_S3D="Not at all" if another household member is selected)), go to
Nonsmoker survey]
[If selected R is a non-smoker (ALL_4C=No if initial respondent is selected or ABS_S3C=No if another
household member is selected), terminate

SCREENER FOR RECONTACT CASES
Scripter: Fill in PPETHM for ABS recontact cases using DOV_PPETHM from look up table

BASE: If DOV_RECONTACT=1
OMB_RECONTACT_ABS [DISP]
Form Approved
OMB No. 0920-1083
Exp. Date 3/31/2023
Extended Evaluation of the National Tobacco Prevention and Control Public Education
Screening Questionnaire
Public reporting burden of this collection of information is estimated to average 5 minutes per
response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data 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 Reports Clearance Officer, 1600
Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1083).
BASE: If DOV_RECONTACT=1
INTRODUCTION. [DISP]
You qualify to participate in a survey that will take about 20-30 minutes to complete. You will be
asked various questions about your experiences with tobacco and television ads about smoking
as well as a few questions about your background. The goal of this survey, which will include
approximately 10,000 individuals nationwide, is to provide more in-depth analysis of mass
media efforts and reactions to television ads.
Your responses will be maintained in a secure manner and no personal identification
information will be passed on to the sponsors of this study. In addition, your name or other
personal information will never be associated with your responses. The data collected for this
research study will be combined with that of all participants before it is analyzed.

If you choose to participate in this survey, you will be contacted to participate in a series of
follow-up surveys on a quarterly basis. The first follow-up survey will occur in approximately 3
months. The additional surveys will take about the same amount of time to complete.
There are no physical risks involved in participating in this study; however, it is possible that you
could find some of the questions to be sensitive. If you find a question during the survey to be
too personal, you may choose not to answer the question. Your participation is strictly voluntary
and you may terminate your participation at any time. The benefit of participating in this study is
to assist the sponsor in determining a nationwide estimate of awareness of an important media
campaign. If you are qualified, [IF OFFPANEL=0: you will be awarded 15,000 bonus points
credited to your KnowledgePanel account for completing the survey.] [IF OFFPANEL=1 and
DOV_INCENTIVE from sample file=20 or missing: you will receive a check for $20 for
completing the survey. / IF OFFPANEL=1 and DOV_INCENTIVE from sample file=40: you will
receive a check for $40 for completing the survey.]
This survey is being conducted on behalf of the Centers for Disease Control and Prevention
(www.cdc.gov) and RTI International (www.rti.org), a non-profit research organization that
conducts studies on many types of health and social issues. [IF OFFPANEL=0: If you have any
questions about this study, you can contact KnowledgePanel Panel Relations at 1-800-7826899 and you will be directed to the appropriate researchers.] If you have any questions about
your rights as a study participant, you can contact RTI’s Human Research Protections Office by
email at orpe@rti.org, or by phone at 1-866-214-2043 (a toll-free number). Please print or save
a copy of this document for your records.
BASE: If OFFPANEL=1 and DOV_RECONTACT=1
REAge [NUMBER BOXES – RANGE 1 TO 12; 1 TO 31; 1900 TO (CURRENT YEAR-1);
prompt once]
Just to be sure we have the correct information, please tell us your birthday.
Here is an example of how to enter a date: if you were born on August 23, 1954, you would
enter the number 8 for month, 23 for day, and 1954 for year.
__MM __DD __YY
SCRIPTER: Compute DOV_REAge from birthday given in REAge. DOV_REAge should show age in
years.

BASE: If DOV_RECONTACT=1 and XACSLANG=4 or missing or
DOV_PPETHM_ABS=missing
QACSLAN1 [S]
Do you speak a language other than English at home?
1. Yes
2. No
BASE: If (DOV_RECONTACT=1 and (XACSLANG=4 or missing) and QACSLAN1=1) or
(DOV_PPETHM_ABS=missing and QACSLAN1=1)
QACSLAN2 [S]
What language do you speak at home other than English?

1. Spanish
2. Chinese (any dialect)
3. Tagalog
4. Vietnamese
5. French
6. German
7. Another language
BASE: If (DOV_RECONTACT=1 and (XACSLANG=4 or missing) and QACSLAN1=1) or
(DOV_PPETHM_ABS=missing and QACSLAN1=1)
QACSLAN3 [S]
How well do you speak English?
1. Very well
2. Well
3. Not well
4. Not at all
Create Data-only variable QACSLANG by using the below logic involving responses to QACSLAN1QACSLAN3
create numeric variable, qacslang, range [1,3]
if qacslan1=2 qacslang=1.
if qacslan1=REFUSED and (respondent is taking survey in English – survey language is based on
Prefer_Lang) qacslang=1.
if qacslan1=REFUSED and (respondent is taking survey in Spanish– survey language is based on
Prefer_Lang) qacslang=3.
if qacslan2=2-7, REFUSED and (respondent is taking survey in English– survey language is based on
Prefer_Lang) qacslang=1.
if qacslan2=2-7, REFUSED and (respondent is taking survey in Spanish– survey language is based on
Prefer_Lang) qacslang=3.
if qacslan2=1 and (qacslan3 =1 or qacslan3=2) qacslang=2.
if qacslan2=1 and (qacslan3 =3 or qacslan3=4) qacslang=3.
if qacslan2=1 and (qacslan3=REFUSED) and (respondent is taking survey in English– survey language is
based on Prefer_Lang) qacslang=2.
if qacslan2=1 and (qacslan3=REFUSED) and (respondent is taking survey in Spanish– survey language
is based on Prefer_Lang) qacslang=3.
DATA ONLY [SINGLE PUNCH]
DOV_ACSLANG – LANGUAGE PROFICIENCY - AGGREGATE OF XACSLANG AND QACSLANG
(QACSLAN1-QACSLAN4)
Instructions: IF XACSLANG=1-3 THEN DOV_ACSLANG=XACSLANG. IF XACSLANG=4 OR NULL
THEN DOV_ACSLANG=QACSLANG. IF XACSLANG=5 THEN DOV_ACSLANG=5.
1. English Proficient
2. Bilingual
3. Spanish Proficient
4. Hispanics who have missing data; re-ask in field
5. Non-Hispanics, not asked
SAMVAR Definition
Variable name: XACSLANG
Type: SP
Variable Text: Primary Language
Response list:Fcounty

1. English Proficient
2. Bilingual
3. Spanish Proficient
4. Hispanics who have missing data; re-ask in field
5. Non-Hispanics, not asked

BASE: If DOV_RECONTACT=1
ALL_G14 [Q, 00000-99999; prompt once]
In what zip code do you live?
Scripter: Terminate if ALL_G14 refused after prompt.

BASE: If DOV_RECONTACT=1
ALL_G14a [S; prompt once]
You told us you live in zip code [SHOW ZIP CODE FROM ALL_G14]. Is this correct?
1. Yes
2. No
Variable name: QMSACAT
Type: SP
[Use crosswalk table based on zip_level_table. xlsx]
[Update this variable if new zip is entered if looped back]
Scripter: If ALL_G14a=“No” or refused after prompt, show ALL_G14 again. Record most current zip code
entered.
Scripter: Record DOV_DMA based on zip code entered using stat_dma lookup table.

BASE: If DOV_RECONTACT=1
S3c [S; prompt twice]
Have you smoked at least 100 cigarettes in your entire lifetime?
1. Yes
2. No
BASE: If S3c=1 or refused
A3 [S; prompt twice]
Do you now smoke every day, some days, or not at all?
1. I smoke every day
2. I smoke on some days
3. I do not smoke at all
CALCULATE DOV_T10W1_SMOKE (1=Current Smoker, 2=Former Smoker, 3=Nonsmoker):
If OFFPANEL=1, use XW1SMOKE from lookup table based on MNO and the following logic to create
DOV_T10W1_SMOKE
If OFFPANEL=0, use XW1SMOKE samvar
If XW1SMOKE=1 or DOV_XW1SMOKE=1 (Current Smoker)
S3c=2 DOV_T10W1_SMOKE=2.

A3=1 DOV_T10W1_SMOKE=1.
A3=2 DOV_T10W1_SMOKE=1.
A3=3 DOV_T10W1_SMOKE=2.
A3=Refused DOV_T10W1_SMOKE=1.
If XW1SMOKE=2 or DOV_XW1SMOKE=2 (Former Smoker)
S3c=2 DOV_T10W1_SMOKE=2.
A3=1 DOV_T10W1_SMOKE=1.
A3=2 DOV_T10W1_SMOKE=1.
A3=3 DOV_T10W1_SMOKE=2.
A3=Refused DOV_T10W1_SMOKE=2.
If XW1SMOKE=3 or DOV_XW1SMOKE=3 (Nonsmoker)
S3c=2 DOV_T10W1_SMOKE=3.
A3=1 DOV_T10W1_SMOKE=1.
A3=2 DOV_T10W1_SMOKE=1.
A3=3 DOV_T10W1_SMOKE=2.
A3=Refused DOV_T10W1_SMOKE=3.
Scripter: Create DOV_SMOKER.
If DOV_T10W1_SMOKE=1 DOV_SMOKER=1 (smoker)
If DOV_T10W1_SMOKE=2 or 3 DOV_SMOKER =2 (nonsmoker)
If A3=1, show SMOKER survey
If A3=2, show SMOKER survey
If A3=3, show NONSMOKER survey
If A3=refused after two prompts:
If OFFPANEL=0 (KP) and XW1SMOKE sample variable=1 (Current Smoker), show SMOKER survey.
If OFFPANEL=0 (KP) and XW1SMOKE sample variable=2 or 3 (Former Smoker or Nonsmoker), show
NONSMOKER survey.
If OFFPANEL=1 (ABS) and XW1SMOKE from lookup table=1 (Current Smoker), show SMOKER survey.
If OFFPANEL=1 (ABS) and XW1SMOKE from lookup table=2 or 3 (Former Smoker or Nonsmoker), show
ABS_END and terminate.
Generate DOV_DATE1, DOV_DATE2, DOV_DATE3, DOV_DATE4, and DOV_DATE5 based on survey
start date:
DOV_DATE1: past 30 days
DOV_DATE2: past 3 months
DOV_DATE3: past 12 months
DOV_DATE4: past 6 months
DOV_DATE5: past 4 months
DOV_DATE6: past 7 days
All DOV_DATE variables should be in text format (e.g., "June 21, 2012").