Form Approved
OMB No. 0920-0910
Exp. Date 01/31/2015
National Tobacco Education Campaign:
Rough
Cut Testing of Print and Radio Ads
Among 18-54 Year Olds
Screener
Public reporting burden of this collection of information is estimated to average 2 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0910).
On behalf of the Centers for Disease Control and Prevention (CDC), we're conducting a study about different health and smoking-specific advertising that you see in the media. Your opinions are very important to us! Please be assured that the purpose of this survey is to gather feedback regarding specific health-related advertising. We do not plan to report your answers individually. We plan to report results from this survey for the group as a whole. Thank you for taking the time to help us!
If you decide to participate and are eligible, you will receive 400 points [note - $2.00] as compensation for your time if you complete the online survey. Your participation in this survey is voluntary.
Screening Criteria:
PROGRAMMER NOTE: EACH QUESTION HAS AN ITALICIZED REFERENCE QUESTION NUMBER, PLEASE DO NOT SHOW THIS, THIS IS FOR BACKEND REFERENCE ONLY.
Screener Section I: DEMOGRAPHICS
Gender:
Male
Female
In what state, city, and zip code do you currently live? ENTER FIVE DIGIT ZIP CODE.
In which of the following categories does your age fall:
Under 18 years of age SCREEN OUT
18-24 years of age
25-34 years of age
35-44 years of age
45-54 years of age
55-64 years of age SCREEN OUT
65-74 years of age SCREEN OUT
75 years of age or older SCREEN OUT
If Alabama and 18-24 years of age
How old are you?
|_|_|
If 18 SCREEN OUT
Do you, or does any member of your household or immediate family work for:
a market research company
an advertising agency or public relations firm
the media (TV/radio/newspapers/magazines)
as a healthcare professional (doctor, nurse, pharmacist, dietician, etc.)
IF ANY OF 1-4 SELECTED, SCREEN OUT.
Number of children (under age 18) living in the household:
None
1-2 children
3-4 children
5 or more children
What is the highest level of education you have completed?
Grade school
Less than high school graduate/some high school
High school graduate or completed GED
Some college or technical school
Received four-year college degree
Some post graduate studies
Received advanced degree
Other: _____________________
Please tell me your race or ethnic background. Do you consider yourself?
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Race: Please select one or more.
White/Caucasian
Black or African-American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Asian
What is your current occupational status? Would you say…?
Employed full time
Employed part time
Unemployed
Homemaker
Student
Retired, or
Disabled
Other:_______________
Don’t Know/Not Sure
Refused
What is your marital status?
Married
Unmarried living with a partner
Divorced
Widowed
Separated, or
Single, never been married
Don’t Know/Not Sure
Refused
Which of the following categories best describe your total, annual household income?
Under $20,000/year
$20,001 - $30,000/year
$30,001 - $40,000/year
$40,001 - $50,000/year
$50,001 - $60,000/year
$60,001 - $80,000/year
$80,001 - $100,000/year
Over
$100,000/year
Screener Section II. TOBACCO HISTORY SCREENING
Have you smoked at least 100 cigarettes in your entire life? SINGLE RESPONSE.
Yes CONTINUE
No
SKIP TO MAIN QUESTIONNAIRE
Do you now smoke cigarettes every day, some days, or not at all? SINGLE RESPONSE.
Every day CONTINUE
Some days CONTINUE
Not at all SKIP NEXT TWO QUESTIONS
On how many of the past 30 days did you smoke cigarettes?
Enter number: _______
On the average, on those (INSERT QUESTION #36a RESPONSE) days, how many cigarettes did you usually smoke each day?
FILL IN NUMBER ______
During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking? SINGLE RESPONSE.
Yes CONTINUE
No SKIP NEXT QUESTION
About how long has it been since you completely quit smoking cigarettes? FILL IN NUMBER FOR UNIT THAT APPLIES.
_____ Days (RANGE OF 0 TO 30)
_____ Weeks (RANGE OF 0 TO 5)
_____ Months (RANGE OF 0 TO 12)
_____ Years (RANGE OF 0 TO 50)
GENERAL SCREEN OUT MESSAGE UNLESS OTHERWISE NOTED
Thank you for your participation in this study. Unfortunately, your responses indicate that you are not qualified for this particular study, or that we have already reached our required quota of responses from participants similar to you. We appreciate your enthusiasm for our study and hope you will join us on future surveys!
| File Type | application/msword |
| File Title | OSH Media Rough Cut Survey |
| Author | Carol Haney |
| Last Modified By | Michelle Murphy |
| File Modified | 2012-01-24 |
| File Created | 2012-01-16 |