Attachment C. Visit 1 Screener

Attachment C

Visit 1 Eligibility Screener

Form Approved

OMB NO.__________

Exp. Date__________

Visit 1 Eligibility Screener

Public reporting burden of this collection of information is estimated to average 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 may 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 E-11, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

Visit 1 SCREENER		(To be electronically entered by lab staff.)
1. Please tell me which of these best describes your race and ethnic group:		White, Non-Hispanic   White, Hispanic African American, Non-Hispanic African American, Hispanic American Indian or Alaskan Native Asian or Pacific Islander Something else   (SPECIFY) __________________________________ ELIGIBLE: Dependent upon cell availability
2. Do you smoke cigarettes daily?		YES (ELIGIBLE) NO (INELIGIBLE)
3. How many cigarettes do you smoke on a typical day?		# OF CIGARETTES PER DAY min ≥ 6 max ≤ 40
4. How long has it been since you smoked your last cigarette?		HOURS MINUTES 1 HOUR
5. On a scale from 1-10, with 10 being highest, how much do you “want” a cigarette right now?		1 - not at all 5 - moderately (“kind of”) want a cigarette 10 - really want/need a cigarette
6. What is your current brand of cigarettes?		RECORD VERBATIM:_______________
7. Is your usual brand a “light”, “ultralight”, “full-flavored”, or a menthol cigarette?		LIGHT FULL-FLAVORED NON-MENTHOL ULTRALIGHT FULL-FLAVORED MENTHOL
8. How long have you been smoking your current brand of cigarettes?		< 3 mos ( INELIGBLE) ≥ 3 mos (ELIGIBLE)
9. Have you switched from a “full-flavored” brand to a “light” or “ultralight” brand in the past 9 months?		YES (INELIGIBLE) NO (ELIGIBLE)
10. Do you use any other tobacco products? (chewing tobacco, nicotine gum, etc.)		YES (INELIGIBLE) NO (ELIGIBLE)
11. What is your date of birth?		DATE OF BIRTH MONTH DAY YEAR ELIGIBLE = ≥18yrs
12. Are you currently trying to quit smoking?		YES (INELIGIBLE) NO (ELIGIBLE)
13. Have you ever been told by a doctor that you had any problems with your lungs?		YES (INELIGIBLE) NO (ELIGIBLE)
SPECIFY:
14. Have you ever been told by a doctor that you had any kind of heart problem?		YES (INELIGIBLE) NO (ELIGIBLE)
SPECIFY:
15. Have you ever been diagnosed with cancer or a precancerous lesion?		YES (INELIGIBLE) NO (ELIGIBLE)
SPECIFY: