Appendix 3 Forced Exposure Follow-up Survey

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APPENDIX 3: FORCED EXPOSURE FOLLOW-UP SURVEY

OMB No. 0930-0196

Expiration Date: 09/30/2013

Public Burden Statement: 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. The OMB control number for this project is 0930-0196. Public reporting burden for this collection of information is estimated to average 10 minutes per respondent per year, as no time is necessary for reviewing instructions, searching existing data sources, gathering and maintaining data, nor completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 8-1099, Rockville, Maryland, 20857.

web

Application ID#:

URL:

DRAFT – April 20, 2012

Project Registration #	__N__ TRANSLATIONS
GALLUP PANEL
City Center:	X SURVEY DESIGN:
CSAP Forced Exposure Follow-up
Lloyd/Purcell	__Y__ PANEL SAMPLE
Mark Rupprecht, Programmer
February, 2012	n=2500

Sb. FORM: (Code from Roadbed)

1 FORM 1 (Advertisements) (n=1250)

2 FORM 2 (Control) (n=1250)

Welcome to The Gallup Panel Underage Drinking

Prevention Survey.

This survey will only take you a few minutes to complete. Please enter your ID Code from the e-mail invitation you received earlier and click the "Begin Survey" button to continue.

ID Code

<Begin Survey>

(PROGRAMMER NOTE: If incorrect ID Code, display the following error message:)

The ID Code you have entered is invalid. Please carefully re-enter your ID Code.

(PROGRAMMER NOTE: If no ID Code is entered, display the following error message:)

You must enter an ID Code to continue.

(PROGRAMMER NOTE: If completed survey found in database for this ID Code, display the following error message:)

A survey has already been completed with this ID Code. Thank you for your participation.

If you feel you have received this message in error, please contact Gallup Panel Support at [email protected] or call 1-888-297-8999.

(PROGRAMMER NOTE: Display the following at the bottom of each screen:)

If you need assistance completing this survey, need to change any of your contact information, or have other questions about The Gallup Panel, please contact Gallup Panel Support by sending an e-mail to [email protected] or by calling 1-888-297-8999 from 8:00 a.m. to 8:00 p.m. Eastern Time, Monday through Thursday, or 8:00 a.m. to 6:00 p.m. Eastern Time on Fridays.

Do not print, store, or copy this page.

Copyright © 1994-2000, 2012 Gallup, Inc. All rights reserved. Privacy Policy

**HOUSEHOLD SAMPLE:

X Single Household

Multi-household

Dear (Prefix/First Name/Last Name/Suffix):

On behalf of The Gallup Panel, we would like to thank you for being a Panel member. It is important that your opinions be heard.

(IF CODE 1 IN SB , DISPLAY:)This survey is a follow-up

to the survey you took a few months ago. In this

survey, we would like to get your feedback on the you

information you received on underage drinking

prevention.

(IF CODE 2 IN SB , DISPLAY:)This survey is a follow-up

to the survey you took a few months ago.

If you do not complete the survey in one sitting, you can log on again and the survey will resume where you left off. You will not have to repeat any of the questions you have already answered.

As usual, your responses are confidential. The Gallup Panel will never release any of your information.

Thank you in advance for your valued input.

Sincerely,

Darby Miller-Steiger

Panel Relationship Manager

Sa1. Just to confirm, are you (Prefix/First Name/Last Name/Suffix)?

1 Yes

2 No

(Error Message:)

A response is required to continue.

(If code 1 in Sa1, Skip to S1;

Otherwise, Continue)

We're sorry, but this Gallup Panel survey was intended for (Prefix/First Name/Last Name/Suffix).

If you feel you have received this message in error, or if you have questions about this survey, please contact Gallup Panel Support at [email protected] or call 1-888-297-8999.

Thank you. You may now close your browser or go to another Web site.

For the following questions, I want you to think about your child/children who are between the ages of 9 and 15.

Q1. Currently, do you see drinking alcohol as an issue to be concerned with you child?

1. Yes

2. No

Q2. Do you think there is anything you could do to prevent your child/children from drinking alcohol?

1 Yes (IF CODE 1 in Q2 continue)

2 No (SKIP TO Q4)

Q2a. What could you do to prevent your child/children from drinking alcohol? (Fill in response)(Allow 400 characters)

Q3. Have you ever had a conversation with your child/children about alcohol?

1. Yes (IF CODE 1 in Q3 continue)

2. No (SKIP TO Q4)

Q3a. Within the last 3 months, how often have you talked to your child/children about drinking alcohol?

1. Once

2. Twice

3. Three times

4. Four times

5. Five times or more

6 Not at all in the 3 months

Q3b. Within the last 3 months, how often have you talked to your child/children about the dangers of drinking alcohol?

1. Once

2. Twice

3. Three times

4. Four times

5. Five times or more

6. Not at all in the 3 months

Q4. Have you talked with the parents of your child’s/children’s friends about their children drinking alcohol?

1. Yes (IF CODE 1 in Q3 continue)

2. No (SKIP TO Q5)

Q4a. Within the last 3 months, how often have you talked with the parents of your child’s/children’s friends about children drinking alcohol?

1. Once

2. Twice

3. Three times

4. Four times

5. Five times or more

6 Not at all in the 3 months

Q5. If you were concerned or wanted to find information about drinking, where would you go to find information to help you address this concern? (Fill in response) (Allow 400 characters)

(PROGRAMMER NOTE: IF CODE 1 IN SB CONTINUE, OTHERWISE SKIP TO SECTION FOR CONTROL ONLY)

Q6. Without looking back at any of the materials, what organization sponsored this ad?

1 CDC

2 SAMHSA

3 HHS

4 NIH

8 Don't know

Q7. How likely would you be to seek out more information about this organization?

1 Not at all likely

2

3

4

5 Extremely likely

Q8. Thinking about all the materials and information you received, please describe what you found most helpful? Please be as specific as possible. (Fill in response) (Allow 400 characters)

Q9. How relevant would you say these materials are to you?

1. Not at all relevant

2

3

4

5 Extremely relevant

Q10. Did these materials leave an impression on you?

1. Did not leave an impression

2

3

4

5 Left impression

Q11. To what extent did you like these materials?

1 Did not like it at all

2

3

4

5 Liked it a lot

(If 1, 2, or 3 in #Q11, Continue;

If No response, go to #Q12;

Otherwise, Skip to Q11B)

Q11A.What didn’t you like about them? (Fill in response) (Allow 200 characters)

(All in #11A, Skip to #12)

Q11B.What did you like about them? (Fill in response) (Allow 200 characters)

Q12. How likely are you to take any of the following actions related to your child/children and underage drinking?

A. Have a conversation with your child/children about underage drinking in the next 30 days?

5 Very likely

4

3

2

1 Not at all likely

7 DK

B. Let your child/children know how you feel about them drinking?

5 Very likely

4

3

2

1 Not at all likely

7 DK

C. Talk to your child’s/children’s friends’ parents about underage drinking?

5 Very likely

4

3

2

1 Not at all likely

7 DK

D. Search the Internet for more information about underage drinking?

5 Very likely

4

3

2

1 Not at all likely

7 DK

E. Learn more about where your child/children is/are?

5 Very likely

4

3

2

1 Not at all likely

7 DK

G. Learn more about who your child’s/children’s friends are?

5 Very likely

4

3

2

1 Not at all likely

7 DK

H. Learn more about who your child/children is/are with?

5 Very likely

4

3

2

1 Not at all likely

7 DK

I. Monitor your child’s/children’s online activity

5 Very likely

4

3

2

1 Not at all likely

7 DK

Q13. Since receiving the materials, have you visited the Web site www.underagedrinking.samhsa.gov?

1. Yes (IF CODE 1 continue)

2. No (SKIP TO Q14)

Q13a. How many times have you visited the Web site?

1. Once

2. Twice

3. Three times

4. Four times

5. Five times or more

6 Not at all

Q14. How likely are you to Visit the www.underagedrinking.samhsa.gov

Web site for more information?

5 Very likely

4

3

2

1 Not at all likely

7 DK

PROGRAMMER NOTE: CONTINUE ONLY IF SB=2

CONTROL GROUP QUESTIONS:

How likely are you to take any of the following actions related to your children and underage drinking? (Rotate A-P, keeping B and C, D and E, F and G, H and I, K and L, M and N, O and P together as sets)

A. Have a conversation with your child/children about underage drinking in the next 30 days?

5 Very likely

4

3

2

1 Not at all likely

7 DK

B. Let your child/children know how you feel about them drinking alcohol?

5 Very likely

4

3

2

1 Not at all likely

7 DK

C. Talk to your child’s/children’s friends’ parents about underage drinking?

5 Very likely

4

3

2

1 Not at all likely

7 DK

D. Visit the www.underagedrinking.samhsa.gov Web site for more information?

5 Very likely

4

3

2

1 Not at all likely

7 DK

E. Search the Internet for more information about underage drinking?

5 Very likely

4

3

2

1 Not at all likely

7 DK

F. Seek information about where your child/children is/are?

5 Very likely

4

3

2

1 Not at all likely

7 DK

G. Seek information about who your child’s/children’s friends are?

5 Very likely

4

3

2

1 Not at all likely

7 DK

H. Seek information about who your child/children are with?

5 Very likely

4

3

2

1 Not at all likely

7 DK

I. Monitor your child’s/children’s online activity

5 Very likely

4

3

2

1 Not at all likely

7 DK

(PROGRAMMER NOTE: Right above the "Submit Survey" button, display:)

Please submit your survey to Gallup by clicking the "Submit Survey" button below. Once you close your browser, you will no longer be able to view the survey or change your responses.

<Submit Survey>

Thank you for participating in The Gallup Panel Underage Drinking Prevention Survey. Your opinions do count.

Please visit https://panelmembers.gallup.com/ to read about new findings from The Gallup Panel, meet other Panel members, update your contact information, and more.

You may now close your browser or go to another Web site.

Gallup panel 2012 CSAP UAD FORCED EXPOSURE FOLLOW-UP SURVEY Web 02/02/21