Att C_--_Online_Survey

Attachment C: Online Survey

Form Approved

OMB No. __0920-XXXX__

Exp. Date _xx/xx/20xx_

Public Reporting burden of this collection of information is estimated at 10 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 many 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, GA 30333; Attn: PRA (0920-XXXX).

Online Survey

Welcome, and thank you for agreeing to participate in this research project!

The whole survey should take 10 minutes to complete, and when you are finished you will be able to see how some of your responses compared to everyone else’s.

Below are a few questions about how you get information and things you do for fun.

The purpose of this survey is to get “top of mind” reactions to possible channels for communications on healthy relationships. These questions are samples only, since the specific channels will be determined through formative research.

1. How many friends do you regularly keep in touch with? (Select one)

( ) less than 10

( ) 10-14

( ) 25-44

( ) 45-64

( ) 65-74

( ) 75 or more

2. How many hours a day do you usually spend talking with friends or communicating with them online (for example, using email, IM, etc.)?

( ) never or less than 1 hour a day

( ) 2-5 hours a day

( ) 6-9 hours a day

( ) 10 hours or more a day

3. How likely are you to go to a music festivals this year?

( ) not at all likely

( ) somewhat unlikely

( ) somewhat likely

( ) very likely

4. What music festivals are you likely to go to this year?

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The next questions are about different ways we might want to communicate with you and people your age about healthy relationships.

5. I would be interested in having companies send me new products to try so I can be the first to tell me friends about them.

( ) strongly disagree

( ) somewhat disagree

( ) neither agree nor disagree

( ) somewhat agree

( ) strongly agree

6. What type of radio station(s) do you normally listen to? (Select all answers that apply to you)

( ) music

( ) news

( ) religious

( ) sports

( ) talk and information

( ) news

( ) other, specify: ___________________________________________________________

7. Below is a list of magazines. Please check which ones, if any, you read regularly (most issues). (Select all answers that apply to you)

( ) Seventeen

( ) CosmoGirl!

( ) Teen Vogue

( ) Teen Magazine

( ) Girls’ Life

( ) YM

( ) J14

( ) Relate

( ) Nickelodeon Magazine

( ) Sports Illustrated

( ) Sports Illustrated for Kids

( ) other, specify: ___________________________________________________________

8. Which, if any, TV stations do you normally watch? (Select all answers that apply to you)

( ) Nickelodeon

( ) Disney Channel

( ) ABC Family

( ) Discovery Channel

( ) ESPN

( ) Spike TV

( ) Animal Planet

( ) other, specify: ___________________________________________________________

9. Which, if any, of the following stores have you shopped at in the PAST 3 MONTHS? (Select all answers that apply to you)

( ) Michael’s

( ) American Eagle Outfitters (AE)

( ) Claire’s

( ) Target

( ) Limited Too

( ) Justice

10. What other stores do you shop at regularly?

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11. Which of the following sports do you follow each season (watch on TV, go to the games)?

( ) Major League Baseball

( ) Minor League Baseball

( ) National Football League

( ) College Football

( ) National Basketball League

( ) College Basketball

( ) National Hockey League

( ) Major League Soccer

( ) World Wide Wrestling Federation

( ) Golf

( ) Tennis

( ) other, specify: ___________________________________________________________

12. How often do you make your recommendation to others [insert topic] by each of the following?

	Never	Less than once per week	A few times a week	Once a day	2-10 times per day	11-20 times per day	21-39 times per day	40 or more times per day
12a. By email
12b. In person
12c. By phone
12d. By texting
12e. In a blog
12f. In a letter
12g. On a social networking site such as MySpace or Facebook

13. Sometimes organizations like to make free things or organize events for kids that help them learn about important topics such as being healthy, making good choices, staying safe etc. Which of the following are things would encourage you to participate y? (“X” all answers that apply to you)

( ) tickets to a professional sports game

( ) tickets to a concert

( ) tickets to an outdoor music festival

( ) badge or widget

( ) Facebook/MySpace page

( ) Promotional T-shirt from a retail partner

14. What is your general impression of this idea?

____________________________________________________________________________________________________________________________________________________________________________________

15. If your favorite store held a T-shirt design contest for people your age to promote healthy relationships, how likely would you be to participate in the contest:

( ) not at all likely

( ) somewhat unlikely

( ) somewhat likely

( ) very likely

17. What are stores you shop at where we could hold a T-shirt design contest that you would be likely to participate in?

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19. On a scale of 1 to 5, please rate the following prizes in terms of how much they would make you want to participate in a T-shirt design contest promoting healthy relationships, with 1 being prizes that would definitely make you want to participate and 5 being prizes that would not influence your decision to participate either way:

	Would definitely make me want to participate				Would not influence my decision to participate either way
	1	2	3	4	5
20a. Tickets to the a Festival
20b. Tickets to a concert
20c. My T-shirt design produced and sold in stores with proceeds to benefit a non-profit
20d. A $100 gift card good at the sponsoring retail store
20e. Retail store’s Web site featured my T-shirt design on the homepage for one week

20. What other prizes would make you want to participate in a T-shirt design contest?

____________________________________________________________________________________________________________________________________________________________________________________

21. What is your general reaction to the idea of a T-shirt design contest for people your age promoting healthy relationships?

____________________________________________________________________________________________________________________________________________________________________________________

24. How likely are you to link to a page on healthy relationships on a social networking site, such as Facebook or MySpace?

( ) not at all likely

( ) somewhat unlikely

( ) somewhat likely

( ) very likely

Below is a list of possible locations where you might see information about healthy relationships. For each location, please indicate how likely you would be to pick up and use this information if you saw it in each of these places in your community?

25. If you got information about healthy relationships at a Boys and Girls Club, how likely would you be to pick it up?

( ) I never go to Boys and Girls Clubs

( ) not at all likely

( ) somewhat unlikely

( ) somewhat likely

( ) very likely

26. If you got information about healthy relationships at a Boy Scout or Girl Scout camp, how likely would you be to pick it up?

( ) I never go to Boy Scout or Girl Scout camp

( ) not at all likely

( ) somewhat unlikely

( ) somewhat likely

( ) very likely

27. If you got information about healthy relationships from a friend on Facebook/MySpace who was trying to promote healthy dating relationships, how likely would you be to accept the comment so it gets posted on your page?

( ) I’m not on any social networking sites like Facebook or MySpace

( ) not at all likely

( ) somewhat unlikely

( ) somewhat likely

( ) very likely

28. If you got information about healthy relationships from your sports coach, how likely would you be to take the information?

( ) I don’t have a sports coach

( ) not at all likely

( ) somewhat unlikely

( ) somewhat likely

( ) very likely

29. Below is a list of different types of materials you could use to communicate with your friends and other people your age about healthy relationships. On a scale of 1 to 5, please rate each type of material in terms of how useful it would be to you if you wanted to communicate with friends or other people your age about healthy relationships, with 1 being very useful and 5 being not useful at all.

	Very useful				Not useful at all
	1	2	3	4	5
29a. Facebook/ MySpace page about healthy relationships
29b. Badge or Widget
29c. Magazine
29d. Books
29e.TV
29f. Comic Books
29g. Movie
29h. Video Games
29i. Radio

30. What other materials would you use to communicate with your friends and other people your age about healthy relationships?

____________________________________________________________________________________________________________________________________________________________________________________

31. What other ideas do you have about how we could share information about healthy relationships with you and other people your age?

____________________________________________________________________________________________________________________________________________________________________________________

The last set of questions below will give us some background information about you:

32. How old are you?

( ) 11

( ) 12

( ) 13

( ) 14

( ) Other

33. What grade are you in?

( ) 6^th grade

( ) 7^th grade

( ) 8^th grade

( ) Other

34. Which of the following comes the closest to describing your race?

( ) American Indian or Alaska Native

( ) Asian

( ) Black or African American

( ) Native Hawaiian or Other Pacific Islander

( ) White

35. Which of the following comes the closest to describing your ethnicity?

( ) Hispanic or Latino

( ) Not Hispanic or Latino

36. How would you describe the neighborhood you live in?

( ) Urban

( ) Suburban

( ) Rural

Thank you for completing the survey!

Click the link below to see how some of your responses compared to everyone else’s.

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