National Youth Tobacco Survey Questionnaire Supplemental Documents

G. National Youth Tobacco Survey Questionnaire Supplemental Documents

G1. Parental Permission Form Distribution Script

G2. Parental Permission Form and Fact Sheet (English Version)

G3. Parental Permission Form and Fact Sheet (Spanish Version)

G4. Parental Permission Form Reminder Notice (English Version)

G5. Parental Permission Form Reminder Notice (Spanish Version)

G6. Questionnaire Administration Guide

G7. Data Collector Confidentiality Agreement

G1. Parental Permission Form Distribution Script

Dear Teacher:

You may wish to read this as you distribute the parental permission forms to encourage student participation in the 2009 National Youth Tobacco Survey.

Thank you.

Our class has been selected to participate in the 2009 National Youth Tobacco Survey conducted by the Centers for Disease Control and Prevention. This survey is designed to focus on tobacco-related beliefs, attitudes, and behaviors, and exposure to influences that promote or discourage tobacco use. Your participation in the survey is very important as you represent thousands of students around the country. Each of you will receive a parental permission form to take home for your parents to sign. Please bring this form back in three days. You must return this form to take part in the survey. IF YOU DO NOT HAVE A SIGNED PARENTAL PERMISSION FORM, YOU MAY NOT TAKE THE SURVEY.

G2. Parental Permission Form and Fact Sheet (English Version)

PARENTAL PERMISSION FORM

Our school is taking part in the 2009 National Youth Tobacco Survey (2009 NYTS). Students in grades 6 through 12 will be asked to fill out a survey about their tobacco-related beliefs, attitudes, and behaviors, intent to use, and exposure to influences that promote or discourage tobacco use. This survey is funded by the Centers for Disease Control and Prevention (CDC).

Students will be asked to fill out a survey that takes about 35 minutes to complete.

Doing this paper and pencil survey will cause little or no risk to your child. The only potential risk is that some students might find certain questions to be sensitive. The survey has been designed to protect your child’s privacy. Students will not put their names on the survey. Also, no school or student will ever be mentioned by name in a report of the results. Your child will get no benefit right away from taking part in the survey. But the results of this survey will help your child and other children in the future. We would like all selected students to take part in the survey, but the survey is voluntary. No action will be taken against the school, you, or your child, if your child does not take part. Students can skip any questions that they do not wish to answer. In addition, students may stop participating in the survey at any point without penalty. If you would like to see the survey, a copy is available in the school office.

State and local school officials and a review board at CDC have approved the survey. You or your child may have questions about your child’s rights as a participant in this research study. If so, please call the CDC Human Research Protections Office at 1-800-584-8814. Please leave a brief message with your name and phone number. Say that you are calling about CDC protocol #4118. We will return your call as soon as possible.

Please read the section below and check one box. Then, sign the form and return it to the school within 3 days. Please see the other side of this form for more facts about the survey. If your child's teacher or principal cannot answer your questions about the survey, call Dr. Danice Eaton of the CDC at 770-488-6143. Thank you.

______________________________________________________________________________

Child’s name: ______________________________________ Grade: ______________

I have read this form and know what the survey is about.

[ ] YES, my child may take part in this survey.

[ ] NO, my child may not take part in this survey.

Parent’s/guardian’s signature: ______________________________ Date:________________

FACT SHEET

Q. Why is the 2009 NYTS being done?

A. The purpose of the National Youth Tobacco Survey (NYTS) is to gather nationally representative data for students in grades 6 through 12 for the following tobacco related topics: prevalence of use (cigarettes, smokeless tobacco, cigars, pipe, bidis, and kreteks), knowledge and attitudes, media and advertising, minor’s access and enforcement, school curriculum, environmental tobacco smoke (ETS) exposure, and cessation.

Q. What are the survey questions about?

A. All questions on the survey relate to student’s attitudes, behaviors, and knowledge about tobacco use, intent to use, exposure to tobacco use, and exposure to tobacco marketing/advertising.

Q. How was my child picked to be in the survey?

A. Nationwide, approximately 20,000 students from 200 schools were selected to participate in the 2009 NYTS. One or two classes (about 25 to 50 students) from each grade 6 through 12 were picked randomly to take part in each school.

Q. Will student’s names be used or linked to the surveys?

A. No. The survey has been designed to protect your child’s privacy. Specially trained field staff will administer the survey in each selected school. Students do not put their name on the survey. When students finish the survey, they place the survey in an envelope and seal it shut. The envelopes are then collected in a big box.

Q. Do students take the survey more than once to see how their behaviors change?

A. No. Students who take part cannot be tracked because their names are not on the survey.

Q. How long does the survey take to fill out?

A. One class period is needed to fill out the written survey.

Q. Does the survey include a physical test?

A. No. The survey does not include a physical test.

G3. Parental Permission Form and Fact Sheet (Spanish Version)

FORMULARIO DE PERMISO DE LOS PADRES

Nuestra escuela está participando en la Encuesta Nacional de la Juventud y el Tabaco 2009 (NYTS 2009). Se invitarán a los estudiantes en los grados 6 hasta 12 completar un cuestionario sobre los conocimientos, las actitudes, y los comportamientos del uso del tabaco, intento de usarlo, y la exposición a las influencias que promueven o desalientan el uso del tabaco. Esta encuesta es auspiciada por Los Centros para el Control y la Prevención de Enfermedades (CDC).

Se necesita un período normal (aproximadamente 35 minutos) para completar el cuestionario.

Contestar este cuestionario de papel y lápiz representa poco o ningún riesgo para su hijo(a). El único riesgo es que a algunos estudiantes, ciertas preguntas les parezcan sensitivas. Los procedimientos de administración de la encuesta fueron diseñados para no revelar la identidad de su hijo(a). Los estudiantes no escriben sus nombres en los cuestionarios. Ninguna escuela o estudiante será identificado en los informes que se publiqen. Su hijo(a) no recibirá beneficios inmediatos por llenar la encuesta. Pero los resultados de esta encuesta ayudarán a su niño y otros niños en el futuro. Nos gustaría que cada estudiante escogido participe en la encuesta, pero la decisión de participar es voluntaria. No le traerá repercusiones a la escuela, a usted, o a su hijo(a) si decide que su hijo(a) no participe. Los estudiantes pueden omitir unas preguntas si no quieren completarlas. También, los estudiantes pueden terminar su participación cuando les gusten, sin repercusiones. Si quisiera usted revisarlo, una copia del cuestionario està disponible en la oficina de la escuela.

Unos oficiales locales y de los estados y un comité de revista de CDC han aprobado la encuesta. Es posible que usted o su hijo(a) tiene preguntas sobre los derechos de su hijo(a) como un participante en esta encuesta. Puede llamar a la Oficina de la Protección de de la Investigación Humana del CDC al 1-800-584-8814. Deje un mensaje breve, incluyendo su nombre y número de teléfono, y que està llamando sobre protocolo #4118. Se le llamará tan pronto como sea posible.

Por favor lea la sección que aparece abajo y marque la respuesta apropriada. Entonces, devuelva el formulario firmado a la escuela en tres días. Lea el reverso de este formulario para más información de la encuesta. Si el maestro de su hijo(a) o el director de su escuela no le puede contestar sus preguntas sobre la encuesta, puede llamar a Danice Eaton del CDC al 770- 488-6143. Muchas gracias.

Nombre de su hijo/a:________________________________ Grado:________

Yo he leido y entiendo este formulario respeto a la encuesta.

[ ] SI, mi hijo(a) tiene mi permiso para participar en la encuesta.

[ ] NO, mi hijo(a) no tiene mi permiso para participar en la encuesta.

Firma de padre o madre/guardián legal: __________________________________________

Fecha: _________________

HOJA DE HECHOS

16. ¿Por qué administra la encuesta NYTS 2009?

18. La intención de la Encuesta NYTS 2009 es para recoger datos nacionales para estudiantes de grados 6 hasta 12 para los siguientes temas relacionados al tabaco: frecuencia del uso de tabaco (cigarrillos, tabaco sin humo, cigarros, pipas, bidis, y kreteks) el conocimiento y el comportamiento, la publicidad y la comercialización del tabaco, acceso al tabaco de jovenes y la ejecución de las leyes, el currículo de la escuela, la exposición al humo del tabaco, y la cesación.

16. ¿Cuáles son los tipos de preguntas?

18. Todas las preguntas en el cuestionario se relacionan con las actitudes, los comportamientos, y los conocimientos de los estudiantes sobre el uso de tabaco, intento de usar el tabaco, y la exposición a la publicidad y a la comercialización del tabaco.

P. ¿Como fue seleccionado a mi hijo(a)?

R. En total, 20,000 estudiantes de 200 escuelas fueron seleccionados para participar en la encuesta NYTS 2009. Una o dos clases (alrededor de 25-50 estudiantes) seleccionarán al azar para completar la encuesta en cada escuela.

P. ¿Se usarán los nombres de los estudiantes o podrán ser identificados en los cuestionarios?

R. No. Los procedimientos de administración de la encuesta fueron diseñados para no revelar la identidad de su hijo(a). La encuesta será administrada por personas especialmente adiestradas en este campo. El estudiante no pondrá su nombre en la encuesta. Cuando el estudiante acabe con la encuesta, el estudiante pondrá su encuesta en un sobre y lo cerrará. Entónces, los sobres serán recogidos en una caja grande.

P. ¿Conducirá la encuesta con los mismos estudiantes otra vez en el futuro para estudiar cómo las prácticas cambian?

R. No. Será imposible identificar a los estudiantes que participen porque los nombres no están en los cuestionarios.

16. ¿Cuánto tiempo necesita la encuesta?

R. El cuestionario de papel y lápiz será administrado durante un período de clase normal.

P. ¿Hay un examen físico?

R. No. La encuesta no incluye un examen físico.

G4. Parental Permission Form Reminder Notice (English Version)

REMINDER

Dear Parent(s):

Your son or daughter’s school is taking part in a national survey of health behaviors.

Recently, a parental permission form was sent to your home. As yet, it has not been returned.

A second copy of the permission form and fact sheet is attached. Please read the form, check the appropriate box, and return it to the school within three days.

Thank you.

G5. Parental Permission Form Reminder Notice (Spanish Version)

RECORDATORIO

La escuela de su hijo/a está participando en una encuesta nacional sobre el comportamiento de riesgo de salud que practica los adolescentes.

Recientemente, a su hijo/a se le dió un formulario de permiso de los padres para que lo trajera a su casa y se le diera a ustedes. Hasta ahora, no hemos recibido su contestación.

Una copia segunda del formulario está incluido. Por favor lea este formulario, márque la contestación propio y devuélvalo a la escuela a lo mas tardar en tres días.

Muchas gracias.

G6. Questionnaire Administration Guide

DATA COLLECTOR SURVEY ADMINISTRATION GUIDE

NATIONAL YOUTH TOBACCO SURVEY

STEP 1 - VERIFY THAT ALL ASSEMBLED STUDENTS HAVE COMPLETED APPROPRIATE PERMISSION FORM PROCESS REQUIRED FOR THIS SCHOOL AND THAT NONPARTICIPATING STUDENTS (IF ANY) HAVE AN ALTERNATE ACTIVITY.

STEP 2 - AFTER STUDENTS ARE SEATED, DISTRIBUTE (OR ASK TEACHERS TO DISTRIBUTE) PENCILS. DO NOT DISTRIBUTE QUESTIONNAIRE BOOKLETS.

STEP 3 - INTRODUCE YOURSELF AND THE SURVEY TO THE CLASS.

This survey is being conducted on behalf of the Centers for Disease Control and Prevention (also known as CDC). Participating in this survey is voluntary and your grade in this class will not be affected, whether or not you answer the questions. However, only a limited number of students like yourselves are participating in this survey in schools all over the Nation. The answers you give are very important so that your results are accurate.

I would like to emphasize that this is not a test of you or our school. The National Youth Tobacco Survey is designed to collect comprehensive data on the attitudes, knowledge, and behaviors of middle and high school students (grades 6‑12) with respect to tobacco, and on other influences that might make a youth susceptible to tobacco use in the future. This will help educators and health officials develop better education programs.

STEP 4 - DISTRIBUTE QUESTIONNAIRES/STUDENT ENVELOPES. EMPHASIZE PRIVACY/ ANONYMITY.

Throughout the entire survey process, we will maintain strict procedures to protect your privacy and allow for your anonymous participation. Please do not write your name on the questionnaire booklet. Your answers are private and we do not want to know your name. Results of this survey will never be reported by names, class, or school. When you finish the survey, place your survey booklet in the envelope provided, seal it, and leave it on your desk.

PAUSE HERE TO ANSWER ANY QUESTIONS...

STEP 5 - INSTRUCT THE CLASS IN FILLING OUT QUESTIONNAIRE.

Now I would like you to look at the questionnaire. Please take a moment to read the instructions on the front cover of the questionnaire.

(PAUSE)

Use the No. 2 pencil you have been given to fill out this survey. Do not use a pen or some other pencil. Notice that for each question on the survey, there is a corresponding set of ovals. For each question, choose the answer that best fits what you know, feel, or do, then fill in the corresponding oval. If you must change an answer, erase your old answer completely.

When you are finished, look over your booklet to make sure that you haven’t skipped any questions. We have allowed 35 minutes for completing the survey. If you finish before that time, place your survey booklet in the envelope, seal it, and stay seated until I ask you to turn it in. It is important that you answer the questions based on what you really know, believe, and do. Don’t pick a response just because you think that’s what someone wants you to say. Your teacher and I are not allowed to answer any questions. Simply do the best that you can. Please begin.

NOTE TO DATA COLLECTOR:

(DO NOT READ ALOUD TO STUDENTS)

While students are taking the survey, work with the teacher to complete the Data Collection Checklist, Make-up list, and fill out the label on the front of the 10 x 13 class envelope. Remember when calculating the enrollment, please do not count students who are on the rolls but for all practical purposes have dropped out, are on suspension, or are on extended medical absence. Please write down the number of booklets enclosed.

STEP 6 - AT THE END OF CLASS PERIOD, COLLECT QUESTIONNAIRES.

STEP 7 - THANK PARTICIPANTS.

I would like to thank all of you for participating in this survey. The information you have provided will be used to develop better health education programs for students like yourselves all around the nation.

STEP 8 - THANK THE TEACHER

G7. Data Collector Confidentiality Agreement

CONFIDENTIALITY AND CONFLICT OF INTEREST AGREEMENT

In consideration of my employment with Macro International Inc. (“Macro”):

1. I recognize that during the course of my employment with Macro, I may have access to confidential and/or proprietary information which is the property of Macro and/or its affiliates, clients and/or other contractors, including but not limited to technical and cost proposals, product and project information not in the public domain, personnel files and salaries, financial data including profit and pricing information, marketing plans, customer and vendor lists and cost data. I agree to maintain the confidentiality of this information and will not, without written permission from the President of Macro, disclose any confidential information at any time during or after my employment at Macro. I further agree that I will use no less than a reasonable degree of care to protect Macro’s confidential and/or proprietary information from disclosure.

2. I acknowledge that, except for material in the Public Domain, all notebooks, memoranda, reports, blueprints and drawings, notes, computer program listings and documents of any kind, any computer disk, or tape or other media containing information obtained pursuant to my project/proposal work at Macro or to which I otherwise gain access, are the exclusive property of Macro’s clients. I agree that, except as required for the performance of my Macro responsibilities, I will not remove from Macro premises any such items without the specific knowledge and consent of the President of Macro. Upon the termination of my employment, I will return all materials received from, or created for, Macro during my employment.

3. I acknowledge that all products relating to the business of Macro which result from work I perform in the course of my employment, or which result from the use of Macro’s facilities, equipment, supplies or confidential information, are the exclusive property of Macro, Macro’s clients, or other organizations, such as professional associations or journals. The use of any such Macro or client products outside of Macro requires the written permission of the President of Macro. Where Macro has the right to use such products to obtain patent, copyright, and/or trade secret protection, I agree to assist Macro (at Macro’s expense) to obtain and enforce its legal rights to such products.

4. I agree that during my employment with Macro and for one year thereafter, I will not, directly or indirectly, solicit, or assist others in soliciting, any employee of Macro for the purpose of causing that employee to terminate employment with Macro.

5. I agree that, should I be required by law, regulation, or court order to disclose Macro confidential or proprietary information, I will, prior to making such disclosure, promptly notify the Company in writing in order to facilitate the Company’s seeking a protective order or other appropriate remedy to protect against such disclosure.

6. I agree that, while employed by Macro, I will abide by the terms and provisions of the Company’s policy on Employee Conflicts of Interest, as published in the Macro Employee Handbook and as reiterated below:

Employee Conflicts of Interest

Macro counts on the dedicated efforts of its staff members. The expertise and capabilities of our employees are the essential building blocks of our success. It is important to all of us that our employees commit their talents and energies to our mutual success and not invest them in support of competitive or conflicting interests. For this reason, Macro generally does not permit staff to engage in employment outside of Macro.

Staff members may not engage in outside consulting or other professional services in areas where Macro provides or contracts for services. Staff are expected to avoid participation in activities or relationships that compete with Macro, that support the efforts of a real or potential Macro competitor, or that might impair or even appear to impair the proper performance of staff job responsibilities. Participation in outside activities, whether compensated or not, is considered to be in conflict with employment at Macro whenever that participation—

• Competes with the Company

• Provides services, either directly or in association with others, which are in competition with services Macro currently provides or might offer

• Provides services and assistance to a competitor or a potential competitor of Macro

• Interferes in any way with the employee’s effective performance of his/her Company duties, such as requiring Company time or facilities, or impacting the employee’s availability to perform essential job duties, project assignments or proposal work.

An employee may not use the Company’s facilities or identifications (such as telephone number and address) to operate another business, profession, or any other work on his/her behalf or on behalf of another employer. All services performed for or on behalf of Macro employee are compensated through the salary paid to the employee and may not be billed to Macro on a consultancy basis.

Participation in conflict-of-interest activities can have serious legal consequences both for the staff member and for Macro. If a staff member is unsure of whether or not an outside activity is a conflict of interest, he/she should discuss the activity with his/her Officer. If a circumstance should arise in which an anticipated activity could present a real or apparent potential conflict of interest, the staff member and his/her Officer are required to obtain the approval of Macro’s President prior to the staff member’s engaging in the activity.

Any exceptions to this Confidentiality and Conflict of Interest Agreement requires the expressed, written authorization of the President of Macro.

_________________________________ _________________________________

Employee Signature Printed Name (Date)

Macro International Inc.

BY: _________________________________ ________________________________

Printed Name (Date)