Household Roster--Main: Baseline & Follow-up 2 Replenishment

OMB Control Number 0910-XXXX

Expiration Date XX/XX/XXXX

Who should complete this survey?

• An adult 18 years old or older who: (1) has lived or stayed at this address for more than 2 months and (2) is knowledgeable about this home.

• Please do not have an adult who is only visiting the home temporarily complete this survey. When answering the questions, please do not include anyone who is away at school or away in the military or anyone who is visiting the home temporarily.

If NO ONE in the household meets these criteria

PLEASE CHECK THE BOX BELOW AND RETURN THE SURVEY IN THE ENCLOSED ENVELOPE

No one in the household meets these criteria.

Survey Instructions

Please use a blue or black pen to complete this survey.

Mark your response by filling in the area (n) or marking an X (x).

Do you agree to participate in this short survey to see if you or a household member are qualified to participate in the study?

Yes, I agree to participate in this survey.

No, I do not want to participate in this survey.

Survey Questions

The first few questions are about people who live or stay in this home.

1. Including you, how many adults 18 years old or older live or stay at this address?

DO NOT INCLUDE anyone who is living somewhere else for more than 2 months, such as a college student living away or someone in the United States Armed Forces on deployment.

	1
	2
	3
	4
	5 or more

2. Including you, how many adults (18 years or older) living or staying in this home are in each age group? (Mark an answer for each row.)

3. 	Adults Including You
   	0	1	2 or more
   Aged 18–24
   Aged 25–34
   Aged 35–54
   Aged 55–64
   Aged 65+

   How many children living or staying in this home are in each age group?
   (Mark an answer for each row)

   	Number of Children
   	0	1	2 or more
   Aged 0–5
   Aged 6–10
   Aged 11–17

4. Including you, how many adults 18 years old and older living or staying in this home… (Mark an answer for each row)

   	Adults Including You
   	0	1	2 or more
   Have an associates, bachelor’s, graduate, or professional degree
   Attended some college but do not have a degree
   Have a high school diploma or GED or less.

5. Is anyone living or staying in this home...

   	Yes	No
   American Indian or Alaska Native
   Asian
   Black or African American
   Hispanic or Latino
   Native Hawaiian or Other Pacific Islander
   White

6. Which best describes the language spoken in your home?

	English only
	Mostly English
	Mostly Spanish
	Mostly another language

7. Which of the following categories best describes the total income of your household from all sources in the past year?

	Less than $10,000
	$10,000 to under $30,000
	$30,000 to under $50,000
	$50,000 to under $70,000
	$70,000 to under $110,000
	$110,00 or more

The next questions are about your home.

8. Is this home…

   	Owned by you or someone in your household
   	Rented
   	Occupied without payment of rent

9. At this house, apartment, or mobile home, do you or any member of this household have access to the Internet?

   	Yes, by paying a cell phone company or internet service provider
   	Yes, without paying a cell phone company or internet service provider
   	No, there is no access to the internet at this household

   

10. In the past 12 months, did you or any member of this household receive benefits from the Food Stamp Program or SNAP (Supplemental Nutrition Assistance Program)? Do NOT include assistance from WIC, the School Lunch Program, or food banks.

	Yes
	No

The next question is about cigarette smoking.

11. Do any of the adults (18 and older) living or staying in this home currently smoke cigarettes?

	Yes
	No

Please provide the following information so we can contact you if we determine that your household is eligible for the study:

First Name:       Last Name:      

Phone Number:    –   –    

Is this a cell phone number? Yes No

Can we text you about the survey? Yes No

E-mail Address:      

You have reached the end of the survey.

Thank you for your time.

Please return this survey to RTI in the postage-paid, addressed envelope we have provided.

Or mail to:

RTI International
ATTN: DATA CAPTURE (0218228.001.003)
5265 Capital Boulevard
Raleigh, NC 27690-1653

If you have questions, please call 1-866-800-9177 or email us at HealthAndMediaStudy@rti.org

OMB No: [FILL NUMBER] Expiration Date: [FILL DATE]

Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 5 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.