Screen and Consent

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

CDC National Media Campaign

- Screening and Informed Consent Process -

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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).

SECTION A: SCREENING QUESTIONS

Thank you for agreeing to take this survey. Our first few questions are primarily for classification purposes and they enable us to select the questions to ask you later in the survey. They will also help us properly analyze responses to this survey.

A1. What is your age?

_______ years old

[terminate if <18 or >54 or skip]

A2. Have you smoked at least 100 cigarettes in your entire life?

Rationale: Key Outcome Indicators 2.08.3, 3.14.1, 1.14.2

NATS Question# 2

1. Yes – Go to A3

2. No – Go to A4

A3. Do you now smoke every day, some days, or not at all?

Rationale: Key Outcome Indicators 2.08.3, 3.14.1

NATS Question #3

1. I smoke every day– GO TO SMOKER QUESTIONNAIRE

2. I smoke on some days - GO TO SMOKER QUESTIONNAIRE

3. I do not smoke at all – GO TO A5

A4. Have you ever tried cigarette smoking, even one or two puffs?

Rationale: Identification of occasional smokers and screener for Key Outcome Indicators 1.10.5, 1.13.2; NATS Question #5

1. YES – [GO TO A5]

2. NO - [GO TO NONSMOKER SURVEY]

A5. During the past 30 days, that is, since [DATE FILL], on how many days did you smoke cigarettes?

Rationale: Key Outcome Indicators 1.14.2, 2.08.2; NATS Question #8

_ _. Number of Days [IF ANSWER > 1 GO TO SMOKER QUESTIONNAIRE].

i DID NOT SMOKE CIGARETTES DURING THE PAST 30 DAYS [If this response is selected go to nonsmoker questionnaire]

INTRODUCTION

According to your previous responses, you qualify to participate in a survey that will take about 25 minutes to complete. You will be asked various questions about your experiences with tobacco and television ads about smoking as well as a few questions about your background. The goal of this survey, which will include approximately 5,000 individuals nationwide, is to provide more in-depth analysis of mass media efforts and smoker’s reactions to television ads.

Your responses will be maintained in a secure manner and no personal identification information will be passed on to the sponsors of this study. In addition, your name or other personal information will never be associated with your responses. The data collected for this research study will be combined with that of all participants before it is analyzed.

If you choose to participate in this survey, you will be contacted to participate in a follow-up survey in approximately 3-4 months. The additional survey will take about the same amount of time to complete.

There are no physical risks involved in participating in this study; however, it is possible that you could find some of the questions to be sensitive. If you find a question during the survey to be too personal, you may choose not to answer the question. Your participation is strictly voluntary and you may terminate your participation at any time. The benefit of participating in this study is to assist the sponsor in determining a nationwide estimate of awareness of an important media campaign. [FILL IF KN]: You will be awarded 20,000 KN points for completing this study. [FILL IF OFF-PANEL]: You will be rewarded $4 for completing this study.

This survey is being conducted on behalf of the Centers for Disease Control and Prevention (www.cdc.gov) and RTI International (www.rti.org), a non-profit research organization that conducts studies on many types of health and social issues. If you have any questions about this study, you can contact Knowledge Networks Panel Relations at 1-800-782-6899 and you will be directed to the appropriate researchers. If you have any questions about your rights as a study participant, you can contact RTI’s Human Research Protections Office by email at [email protected], or by phone at 1-866-214-2043 (a toll-free number). Please print or save a copy of this document for your records.

I have read and understand the information provided above and the study purpose and procedures are clear to me.

1. Yes, I agree to participate in this study.

2. No, I do not wish to participate in this study.

[terminate if no or skip]

4