Youth Screener--Supplemental

OMB Control Number 0910-XXXX

Expiration Date XX/XX/XXXX

ATTACHMENT #16: Social Media Screener

Welcome to the Health and Media Study!

The FDA is developing education programs that aim to improve the health of youth and young adults.

• You are being asked to answer a few questions to see if you are eligible for a study of approximately 7,500 youth across the country.

• You may only complete this questionnaire one time.

• It will only take about 5 minutes to see if you are eligible. If you do not want to answer any questions, you may close out of the survey at any time.

• If we determine you are eligible, you will have the opportunity to continue and complete an additional online survey for $25. You will have the choice between cash or a Visa gift card.

• You may only take that survey one time and you will only receive the $25 one time if you complete it. If we find that you have completed the survey more than once, you may not receive the incentive. Once we complete this check, we will send you the $25 in either cash or a gift card to the address you provide.

• Your answers to the questions will be kept private to the fullest extent allowable by law and your participation is voluntary. Please read our privacy policy before continuing.

If you have any questions about the survey, you can contact our project assistance line at 1-866-800-9177 (toll free) or email us at HealthAndMediaStudy@rti.org.

Do you agree to participate in this short survey?

1. Yes, I agree to participate in this short survey

2. No, I do not agree to participate in this short survey

Note: we do not screen anyone out until the end of the screener (after e-mail) in an effort to (1) not clue them into eligibility criteria and (2) capture their e-mail and other meta-data to ensure they don’t take the screener multiple times after screening out.

[AGE] What is your age?

______________ [Record age – min 5, max 100, no decimals]

[STATE] What state do you live in?

[Drop down box with U.S. States + option to select “I do not live in the U.S.”] 

SO.

Which of the following best represents how you think of yourself? Select all that apply.

1. Straight or heterosexual

2. Bisexual

3. Gay or lesbian

4. Something else [OPEN TEXT]

5. I have not figured out or am in the process of figuring out my sexuality

999. Prefer not to answer  

GI.

What is your gender identity? Select all that apply.

1. Woman/girl

2. Man/boy

3. Non-binary or gender non-conforming

4. Transgender woman/girl

5. Transgender man/boy

6. Another gender identity

999. Prefer not to say

Mental Health. In the past 2 weeks, how often have you been bothered by the following problems?

		Not at all	Several days	More than half the days	Nearly every day
MH_1.	Feeling nervous, anxious or on edge.	1	2	3	4
MH_2.	Not being able to stop or control worrying.	1	2	3	4
MH_3.	Little interest or pleasures in doing things.	1	2	3	4
MH_4.	Feeling down, depressed, or hopeless.	1	2	3	4

PROGRAMMING: Generate MENTALHEALTHSUM = SUM(MH_1 + MH_2 + MH_3 + MH_4).

[DISTRACTOR1] About how often do you visit social media sites, such as Instagram, TikTok, Snapchat, Facebook, or Twitter?  
 

1. Every hour or more 

2. More than once a day 

3. About once a day 

4. 3-5 days a week 

5. 1-2 days a week 

6. Every few weeks or less 

7. I do not have a social media account

[DISTRACTOR2] Which of the following platforms do you use?  
 

1. Hulu

2. Netflix

3. Disney+

4. TubiTV

5. Cable

6. YouTube

7. I do not use any of the above

[DOB] What is your date of birth?  

Please use the following format (MM/DD/YYYY) 

__/__/____ 

 

[EMAIL] 

Please enter your email address: _____________________ [OPEN TEXT] 

The email address you provide is used only for the purposes of this survey and will not be sold or shared. 

 

[EMAIL_VER] 

Please verify your email address: _____________________  

 

[IF SO = 1 AND GI = 1 OR 2 AND MENTALHEALTHSUM < 8, PROCEED TO TERMINATE] 

 

[TERMINATE: IF TERMINATED, DISPLAY NEW SCREEN] 

Based on your responses to our questions, you are not eligible to participate in this study. Thank you for your time.

[IF ELIGIBLE, DISPLAY NEW SCREEN] 

Congratulations! You are eligible and are invited to complete our 30-minute web survey for $25, in either cash or a gift card. Please click the link at the bottom of the page to continue and take the survey now.

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 4 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.