OSH Rough Cut Testing of TV Ads Screener

Form Approved

OMB No. 0920-0910

Exp. Date 01/31/2015

National Tobacco Education Campaign:

OSH Rough Cut Testing of TV Ads Screener

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-xxxx).

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 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

In what state, city, and zip code do you currently live? ENTER FIVE DIGIT ZIP CODE.

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!

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