Att F_--_Online_Survey_Screening_Instrument_for_Parents

Attachment F: Online Survey Screening Instrument for Parents

Form Approved

OMB No. __0920-XXXX

Exp. Date _xx/xx/20xx_

Public Reporting burden of this collection of information is estimated at 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 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 Screening Instrument for Parents

We would like to invite your child to take an online survey. We are conducting research to help public health planners understand the ways youth today spend their time, access information, and interpret messages to better communicate with youth on the topic of healthy relationships. The survey can be completed by your child any time before [date] and should take about 10 minutes to complete.

You will receive [amount] HIpoints* in compensation if your child participates in this survey. Your child will not receive HIpoints; however, he/she will receive instant results, meaning that after completing the survey, they will be able to view a Web page in which they can see how his/her responses compare to other youth who have answered the questions.

But first we'd like to ask you a few questions for background information to see if you have children living in your household who qualify for this study. These questions will only take a few minutes to answer.

1. As part of our study, we’d like to conduct surveys with boys and girls ages 11-14 who are in 6th, 7th, or 8th grade. If you have a child in one of these grades, please indicate below his/her grade level.

( ) 6^th grade Continue

( ) 7^th grade Continue

( ) 8^th grade Continue

( ) Other Terminate

NOTE: Use the following language to “terminate” throughout screening process:

“Thank you for taking the time to answer our questions. Unfortunately, the category you fall into is currently full. If it should open back up, may we contact you later?”

2. How old is your child?

( ) 11 Continue

( ) 12 Continue

( ) 13 Continue

( ) 14 Continue

( ) Other Terminate

*Note to reviewers: Individuals will know that these are incentive points they receive for participating in Harris Interactive polls.

If age and grade level (provided in Q1 and Q2) do not match as follows, terminate: 11 or 12 (for 6^th grade), 12 or 13 (for 7^th grade), 13 or 14 (for 8^th grade).

3. Would you give permission for your child to complete an online survey for research purposes? We are not trying to sell you or your child any new products or services. This is a survey that is being conducted for information-gathering and analytic purposes only.

( ) Yes Continue

( ) No Terminate

3. Is your child a boy or a girl?

( ) Boy Continue

( ) Girl Continue

3. Is the school your child is attending a middle school, junior high or high school?

( ) Middle Continue

( ) Junior high Continue

( ) High Terminate

3. Does your child attend a public school, private school or is he/she home schooled?

( ) Public school Continue

( ) Private school Continue

( ) Home schooled Terminate

3. We want to be certain that our research reflects the country’s diversity. Which of the following comes the closest to describing your child’s racial background?

( ) American Indian or Alaska Native Continue

( ) Asian Continue

( ) Black or African American Continue

( ) Native Hawaiian or Other Pacific Islander Continue

( ) White Continue

7a. Which of the following comes the closest to describing your child’s ethnicity?

( ) Hispanic or Latino Continue

( ) Not Hispanic or Latino Continue

Recruit [quantity] non-Caucasian respondents.

3. We’d like to collect a diverse set of opinions, so can you please tell me your family’s approximate annual household income?

( ) Less than $20,000 Continue

( ) $20,000 - $30,000 Continue

( ) $30,000 - $50,000 Continue

( ) $50,000 - $75,000 Continue

( ) $75,000 - $100,000 Continue

( ) More than $100,000 Continue

3. Is your child available to complete an online survey by [date]? The survey will take approximately 10 minutes.

( ) Yes Continue

( ) No Terminate

Please click on the following link to be redirected to a secure Web site where you will have the opportunity to either provide or decline parental permission for your child to participate. If your child is selected to participate and you have provided permission for your child to participate in the study, you will get instructions for your child on completing the survey.

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