Appendix 4 Natural Exposure Baseline Survey

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APPENDIX 4: NATURAL EXPOSURE BASELINE 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.

paper

Application ID#:

DRAFT – April 20, 2012

Project Registration #	__N__ TRANSLATIONS
GALLUP POLL
City Center:	X SURVEY DESIGN:
CSAP Natural Exposure Baseline
Lloyd/Purcell	__N__ PANEL SAMPLE
Mark Rupprecht, Programmer
February, 2012	n=500

SA. NAME: (enter)

Prefix:

First Name:

Last Name:

Suffix:

Sb. FORM: (Code from oms)

1 PILOT SITE A Attendee

2 PILOT SITE b Attendee

3 PILOT SITE c Attendee

4 PILOT SITE d Attendee

5 PILOT SITE e Attendee

SC. event type: (code from oms)

1 if SB=1 event type is <PILOT SITE A event>

2 if SB=2 event type is <PILOT SITE b event>

3 if SB=3 event type is <PILOT SITE c event>

4 if SB=4 event type is <PILOT SITE d event>

5 if SB=5 event type is <PILOT SITE e event>

SD. event DATE: (code from oms)

1 if SB=1 event DATE is <PILOT SITE A event>

2 if SB=2 event DATE is <PILOT SITE b event>

3 if SB=3 event DATE is <PILOT SITE c event>

4 if SB=4 event DATE is <PILOT SITE d event>

5 if SB=5 event DATE is <PILOT SITE e event>

NOTE: Check the box below if other, non-Campaign underage

drinking prevention materials are being distributed at this

event. □

On behalf of Gallup, we would like to thank you for agreeing to participate in this study. It is important that your opinions be heard.

In this survey, we would like to get your feedback on

issues relating to underage drinking. Your feedback

will help shape the success of a government-sponsored

advertising campaign.

Your responses are confidential. Gallup will never release any of your information.

Before continuing, we must see if you qualify as part of

the group from WHO we are looking for feedback.

SE: Are you the parent or primary caregiver of a child/children between the age of 9 and 15?

1. YES, parent (Continue)

2. YES, primary caregiver (If selected, ask what their relation is to the child/children and Continue)

3. NO (Thanks and terminate)

note: only continue if answered 1 or 2 above

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 regarding your child/children?

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)

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 6 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 6 months

Q3b. Within the last 6 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 6 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 6 months, how often have you talked with the parents of your child’s/children’s friends about drinking alcohol?

1. Once

2. Twice

3. Three times

4. Four times

5. Five times or more

6 Not at all in the 6 months

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

Q6. 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. 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. 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

You are almost done with the survey; we just have a few demographic questions left.

D1. SEX:

1 Male

2 Female

D2. AGE: What is your age? ____________________

D3. What is the highest level of education you have completed?

1 Less than high school graduate (0-11)

2 High school graduate (12)

3 Some college

4 Trade/Technical/Vocational training

5 College graduate

6 Post-graduate work/degree

D4. What is your current marital status?

1 Single/Never been married

2 Married

3 Separated

4 Divorced

5 Widowed

8 Domestic partnership/Living with partner (not legally married)

D5. What is your zip code? ____________________

D6. What is your annual household income?

01 Under $25,000

02 $25,000 to $34,999

03 $35,000 to $49,999

04 $50,000 to $74,999

05 $75,000 to $99,999

06 $100,000 to $149,999

07 $150,000 and over

Thank you again for your participation in this study. In the future, we may have few more questions is it alright for us to re-contact you some other time?

1. Yes (IF CODE 1, CONTINE)

2. No (IF CODE 2, THANK AND END SURVEY)

I just need a few additional details from you before you go.

NAME:

EMAIL ADDRESS:

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

Gallup 2012 CSAP UAD NATURAL EXPOSURE BASELINE SURVEY Web 02/02/21