Attachment G: Screener
G.1. Screener for Eye Tracking and Focus Groups
G.2. Screener for Eye Tracking and Individual Interviews
Screener for Alternative Tobacco Product Study
Eye Tracker + Focus Group (Recruit 12 Men)
OMB
No.: 0925-0645 Expiration
Date: 12/31/2014 Collection
of this information is authorized by The Public Health Service Act,
Section 411 (42 USC 285a). Rights of study participants are
protected by The Privacy Act of 1974. Participation is voluntary,
and there are no penalties for not participating or withdrawing from
the study at any time. Refusal to participate will not affect your
benefits in any way. The information collected in this study will be
kept private under the Privacy Act. Names and other identifiers
will not appear in any report of the study. Information provided
will be combined for all study participants and reported as
summaries. You are being contacted on-line and via newspaper
advertisements and flyers to complete this instrument so that we can
determine whether you are eligible to participate in the Alternative
Tobacco Product Study. Public
reporting burden for 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: NIH, Project Clearance Branch, 6705 Rockledge Drive,
MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0645). Do not
return the completed form to this address.
Male
(see criteria for question 2)
Current
everyday cigarette smokers
(see criteria for questions 8 and 9)
Not
be interested in quitting smoking
(see criteria for question 10)
3
Triads: 12 should be white, non-Hispanic males between 18 and 29
years of age. (see questions
6, 7, & 11 )
6
should have less than high school or completed high school or GED
(see criteria question 13)
6
should have more than high school degree (see criteria question 13)
Thank you for calling about the smoking research study. This study is about how people perceive tobacco products and we would possibly like to include your views. If you do participate in the research study, you will be paid for participating.
I would like to ask you just a few questions to determine if you qualify to participate in the study, which will be in Rockville, Maryland on DATE TBD. Some of the questions are about your cigarette smoking history. Your responses will be kept secure to the extent provided by law and will not be shared with others. My questions today to see if you qualify will only take about 5 minutes.
May I continue with my questions?
Where did you hear about this study?
___Newspaper Advertisement
___Clinical Connection Post
___Flyer
___My Trial Spot Email
___Social Media Post
___Friend or Relative
___Other
[Record gender]
Dismiss>> Female _____
Continue>> Male _____
Are you an employee of the U.S. Federal Government?
Go to question 4 >> Yes_____
Skip to question 5 >> No _____
Do you work in one of the departments of the U.S. Dept. of Health and Human Services*?
Dismiss>> Yes____
Continue>> No____
Are you or anyone in your household . . .
___A computer programmer, developer, professional web designer, or usability tester?
___Employed in advertising, marketing, market research, public relations, public health or health promotion?
___An employee or volunteer in the medical field?
___An employee of the U.S. Department of Health and Human Services or any of its divisions?*
Dismiss >> If any YES *See Annex last page of this screener for a list of divisions under the U.S. Dept. of Health and Human Services.
This study is designed to collect information from people of many ethnic groups. In order to determine if slots for your group are filled, I need to ask you questions about your ethnic heritage. Is that OK?
What is your ethnicity? (Choose one)
___ Not Hispanic or Latino/a (>>CONTINUE)
___ Hispanic or Latino/a (>>DISMISS)
What is your race? (Choose one or more)
___ White (>>CONTINUE)
___ Black or African American (>>DISMISS)
___ American Indian or Alaska Native (>>DISMISS)
___ Asian (>>DISMISS)
___ Native Hawaiian or Other Pacific Islander (>>DISMISS)
Have you smoked at least 100 cigarettes in your entire life? (NOTE: 100 = APPROXIMATELY 5 PACKS in the United States)
____Yes (>>CONTINUE)
____No (>>DISMISS)
Do you now smoke cigarettes every day, some days, or not at all?
____Every day (>>CONTINUE)
____Some days (>>DISMISS)
____ Not at all (>>DISMISS)
Next are statements that smokers have said about quitting. Please tell me which statement best represents what you think right now.
____ I am taking action to quit (for example, cutting down, enrolling in a program) (>>DISMISS)
____ I am starting to think about how to change my smoking patterns (>>DISMISS)
____I think I should quit but I’m not quite ready. (>>CONTINUE)
____ I think I need to consider quitting someday. (>>CONTINUE)
____ I have no thoughts of quitting (>>CONTINUE)
What is your current age?
____ years
Continue >> 18-29 _____
Dismiss>> Over 29 _____
Are you currently in high school?
____ Yes (>>DISMISS)
____ No (>>CONTINUE)
What is the highest grade or level of schooling you completed?
____ I did not complete high school
_____I have a high school diploma or a GED
____ I attended college
Do you read in English?
____ Yes (>>CONTINUE)
____ No (>>DISMISS)
Eye Information: I am now going to ask you some different questions. These are about your eyes because we are going to use some simple technology to track eye and mouse movements during the study.
Do you wear contacts or eyeglasses in order to read the computer screen?
Continue>> Yes _____
Skip to 18>> No_____
Are your glasses for:
Continue>> Reading only _____
Continue>> Seeing distant objects only _____
Dismiss>> Both (Do you wear bifocals, trifocals, layered lenses, or regression lenses) _____
Can you read a computer screen and the Web without difficulty with your contacts and/or
eyeglasses on?
Continue>> Yes _____
Dismiss>> No _____
Do you have cataracts?
Dismiss>> Yes _____
Continue>> No _____
Do you have any eye implants?
Dismiss>> Yes _____
Continue>> No _____
Do you have Glaucoma?
Dismiss>> Yes _____
Continue>> No _____
Do you have strabismus?
Dismiss>> Yes _____
Continue>> No _____
Do you use a screen reader, screen magnifier or other assistive technology to use the
computer and the Web?
Dismiss>> Yes _____
Continue>> No _____
Are either of your pupils permanently dilated?
Dismiss>> Yes _____
Continue>> No _____
Do you have a history of epilepsy, seizures, or sensitivity to flashing lights?
Dismiss>> Yes _____
Invite to Interview>> No _____
**DISMISSAL LANGUAGE: Thank you very much for your time. Unfortunately, you do not qualify, so we won’t be able to include you in our study. Thank you for your time and interest. Have a good day/evening.
**INVITATION TO PARTICIPATE (see following pages for participants)
INVITE TO INTERVIEW
Thank you for answering my questions. As I mentioned this study is being conducted on behalf of the National Cancer Institute. We are interested in your perceptions of tobacco products and we would like to include your views.
In order for us to learn from your experience firsthand, I would like to invite you to participate in this study. The study will last about 2 hours and will take place at the National Cancer Institute, which has parking or is accessible from the White Flint metro stop in Rockville, MD. We ask that you remain in the building for the full 2 hours, but there may be some down time so please bring something to read or do while you wait. We’ll also need you to bring a picture ID that confirms your age in order for you to be admitted. I have a time slot available on DATE.
Does the date, time or location present a problem for you? [If yes, present alternate time option; if no options available, dismiss]
This is not a sales effort of any kind and no one will call on you as a result of your participation. To compensate you for your time and travel expenses, you will receive $75. May we schedule your participation? [If yes, proceed; if no, dismiss]
Do we have your permission to collect your contact information and follow up to remind you once by email and once by phone? [If yes, proceed; if no, dismiss]
Check day and time; see details below.
NAME: _________________________________________________
ADDRESS: _________________________________________________
CITY: _________________________________________________
ZIP CODE: _________________________________________________
PHONE: (DAY) _____________________________________
(EVE) _____________________________________
(CELL) _____________________________________
(EMAIL) _____________________________________
Session Dates/Time Slots
DATE: TBD
ANNEX
List of U.S. Department of Health and Human Services (HHS) Operating and Staff Divisions
Administration for Children and Families (ACF)
Administration for Children, Youth and Families (ACYF)
Administration on Aging (AoA)
Agency for Healthcare Research and Quality (AHRQ)
Agency for Toxic Substances and Disease Registry (ATSDR)
Center for Faith-Based and Neighborhood Partnerships (CFBNP)
Centers for Disease Control and Prevention (CDC)
Departmental Appeals Board (DAB)
Food and Drug Administration (FDA)
Health Resources and Services Administration (HRSA)
Indian Health Service (IHS)
Intergovernmental Affairs and Regional Representatives (IGA)
National Cancer Institute (NCI)
National Coordinator for Health Information Technology (ONC)
National Institutes of Health (NIH)
Office for Civil Rights (OCR)
Office of Consumer Information and Insurance Oversight (OCIIO)
Office of Global Health Affairs (OGHA)
Office of Medicare Hearings and Appeals (OMHA)
Office of the Assistant Secretary for Health (ASH)
Office of the General Counsel (OGC)
Office of the Inspector General (OIG)
Office of the Inspector General (OIG)
Office of the Surgeon General (OSG)
Office on Disability (OD)
Substance Abuse and Mental Health Services Administration (SAMHSA)
Screener for Alternative Tobacco Product Study
Eye Tracker (Recruit 36 Men)
OMB
No.: 0925-0645 Expiration
Date: 12/31/2014 Collection
of this information is authorized by The Public Health Service Act,
Section 411 (42 USC 285a). Rights of study participants are
protected by The Privacy Act of 1974. Participation is voluntary,
and there are no penalties for not participating or withdrawing from
the study at any time. Refusal to participate will not affect your
benefits in any way. The information collected in this study will be
kept private under the Privacy Act. Names and other identifiers
will not appear in any report of the study. Information provided
will be combined for all study participants and reported as
summaries. You are being contacted on-line and via newspaper
advertisements and flyers to complete this instrument so that we can
determine whether you are eligible to participate in the Alternative
Tobacco Product Study. Public
reporting burden for 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: NIH, Project Clearance Branch, 6705 Rockledge Drive,
MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0645). Do not
return the completed form to this address.
Male
(see criteria for question 2)
Current
everyday cigarette smokers
(see criteria for questions 8 and 9)
Not
be interested in quitting smoking
(see criteria for question 10)
27
should be white non-Hispanic males between 18 and 29 years of age
(see criteria for questions 6 , 7, & 11)
18
should have less than high school or completed high school or GED
(see criteria question 13)
9
should have more than high school degree (see criteria question
13)
9
should be males between 18 and 29 years of age from one of the
following ethnic categories (At least one from each category. See
criteria for questions 6 and 7)
Hispanic
or Latino/a
Black
or African American
American
Indian or Alaska Native
Asian
Native
Hawaiian or Other Pacific Islander
Thank you for calling about the smoking research study. This study is about how people perceive tobacco products and we would possibly like to include your views. If you do participate in the research study, you will be paid for participating.
I would like to ask you just a few questions to determine if you qualify to participate in the study, which will be in Rockville, Maryland on DATE TBD. Some of the questions are about your cigarette smoking history. Your responses will be will be kept secure to the extent provided by law and will not be shared with others. My questions today to see if you qualify will only take about 5 minutes.
May I continue with my questions?
Where did you hear about this study?
___Newspaper Advertisement
___Clinical Connection Post
___Flyer
___My Trial Spot Email
___Social Media Post
___Friend or Relative
___Other
[Record gender]
Dismiss>> Female _____
Continue>> Male _____
Are you an employee of the U.S. Federal Government?
Go to question 4 >> Yes_____
Skip to question 5 >> No _____
Do you work in one of the departments of the U.S. Dept. of Health and Human Services*?
Dismiss>> Yes____
Continue>> No____
Are you or anyone in your household . . .
___A computer programmer, developer, professional web designer, or usability tester?
___Employed in advertising, marketing, market research, public relations, public health or health promotion?
___An employee or volunteer in the medical field?
___An employee of the U.S. Department of Health and Human Services or any of its divisions?*
Dismiss >> If any YES *See Annex last page of this screener for a list of divisions under the U.S. Dept. of Health and Human Services.
This study is designed to collect information from people of many ethnic groups. In order to determine if slots for your group are filled, I need to ask you questions about your ethnic heritage. Is that OK?
What is your ethnicity? (Choose one)
___ Not Hispanic or Latino/a
___ Hispanic or Latino/a
What is your race? (Choose one or more)
___ White
___ Black or African American
___ American Indian or Alaska Native
___ Asian
___ Native Hawaiian or Other Pacific Islander
Have you smoked at least 100 cigarettes in your entire life? (NOTE: 100 = APPROXIMATELY 5 PACKS in the United States)
____Yes (>>CONTINUE)
____No (>>DISMISS)
Do you now smoke cigarettes every day, some days, or not at all?
____Every day (>>CONTINUE)
____Some days (>>DISMISS)
____ Not at all (>>DISMISS)
Next are statements that smokers have said about quitting. Please tell me which statement best represents what you think right now.
____ I am taking action to quit (for example, cutting down, enrolling in a program) (>>DISMISS)
____ I am starting to think about how to change my smoking patterns (>>DISMISS)
____ I think I should quit but I’m not quite ready. (>>CONTINUE)
____ I think I need to consider quitting someday. (>>CONTINUE)
____ I have no thoughts of quitting (>>CONTINUE)
What is your current age?
____ years
Continue>> 18-29 _____
Dismiss>> Over 29 _____
Are you currently in high school?
____ Yes (>>DISMISS)
____ No (>>CONTINUE)
What is the highest grade or level of schooling you completed?
____ I did not complete high school
_____I have a high school diploma or a GED
____ I attended college
Do you read in English?
____ Yes (>>CONTINUE)
____ No (>>DISMISS)
Eye Information: I am now going to ask you some different questions. These are about your eyes because we are going to use some simple technology to track eye and mouse movements during the study.
Do you wear contacts or eyeglasses in order to read the computer screen?
Continue>> Yes _____
Skip to 18>> No_____
Are your glasses for:
Continue>> Reading only _____
Continue>> Seeing distant objects only _____
Dismiss>> Both (Do you wear bifocals, trifocals, layered lenses, or regression lenses) _____
Can you read a computer screen and the Web without difficulty with your contacts and/or
eyeglasses on?
Continue>> Yes _____
Dismiss>> No _____
Do you have cataracts?
Dismiss>> Yes _____
Continue>> No _____
Do you have any eye implants?
Dismiss>> Yes _____
Continue>> No _____
Do you have Glaucoma?
Dismiss>> Yes _____
Continue>> No _____
Do you have strabismus?
Dismiss>> Yes _____
Continue>> No _____
Do you use a screen reader, screen magnifier or other assistive technology to use the
computer and the Web?
Dismiss>> Yes _____
Continue>> No _____
Are either of your pupils permanently dilated?
Dismiss>> Yes _____
Continue>> No _____
Do you have a history of epilepsy, seizures, or sensitivity to flashing lights?
Dismiss>> Yes _____
Invite to Interview>> No _____
**DISMISSAL LANGUAGE: Thank you very much for your time. Unfortunately, you do not qualify, so we won’t be able to include you in our study. Thank you for your time and interest. Have a good day/evening.
**INVITATION TO PARTICIPATE (see following pages for participants)
INVITE TO INTERVIEW
Thank you for answering my questions. As I mentioned this study is being conducted on behalf of the National Cancer Institute. We are interested in your perceptions of tobacco products and we would like to include your views.
In order for us to learn from your experience firsthand, I would like to invite you to participate in this study. The study will last about 1 hour and will take place at the National Cancer Institute, which has parking or is accessible from the White Flint metro stop in Rockville, MD. We ask that you remain in the building for the full hour. We’ll also need you to bring a picture ID that confirms your age in order for you to be admitted. I have a time slot available on DATE.
Does the date, time or location present a problem for you? [If yes, present alternate time option; if no options available, dismiss]
This is not a sales effort of any kind and no one will call on you as a result of your participation. To compensate you for your time and travel expenses, you will receive $50. May we schedule your participation? [If yes, proceed; if no, dismiss]
Do we have your permission to collect your contact information and follow up to remind you once by email and once by phone? [If yes, proceed; if no, dismiss]
Check day and time; see details below.
NAME: _________________________________________________
ADDRESS: _________________________________________________
CITY: _________________________________________________
ZIP CODE: _________________________________________________
PHONE: (DAY) _____________________________________
(EVE) _____________________________________
(CELL) _____________________________________
(EMAIL) _____________________________________
Session Dates/Time Slots
DATE: TBD
ANNEX
List of U.S. Department of Health and Human Services (HHS) Operating and Staff Divisions
Administration for Children and Families (ACF)
Administration for Children, Youth and Families (ACYF)
Administration on Aging (AoA)
Agency for Healthcare Research and Quality (AHRQ)
Agency for Toxic Substances and Disease Registry (ATSDR)
Center for Faith-Based and Neighborhood Partnerships (CFBNP)
Centers for Disease Control and Prevention (CDC)
Departmental Appeals Board (DAB)
Food and Drug Administration (FDA)
Health Resources and Services Administration (HRSA)
Indian Health Service (IHS)
Intergovernmental Affairs and Regional Representatives (IGA)
National Cancer Institute (NCI)
National Coordinator for Health Information Technology (ONC)
National Institutes of Health (NIH)
Office for Civil Rights (OCR)
Office of Consumer Information and Insurance Oversight (OCIIO)
Office of Global Health Affairs (OGHA)
Office of Medicare Hearings and Appeals (OMHA)
Office of the Assistant Secretary for Health (ASH)
Office of the General Counsel (OGC)
Office of the Inspector General (OIG)
Office of the Inspector General (OIG)
Office of the Surgeon General (OSG)
Office on Disability (OD)
Substance Abuse and Mental Health Services Administration (SAMHSA)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | kaufmana |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |