National Adult Tobacco Survey Screener for landline users

Form Approved

OMB No. 0920-0828

Exp. Date xx/xx/xxxx

H-1. Landline Screener

LINTRO1

/ASK ALL/

INTERVIEWER: PLEASE READ SLOWLY AND DISTINCTLY

L1. Hello, my name is [NAME FILL]. I'm calling for the CDC, the Centers for Disease Control and Prevention. The CDC is a federal agency charged with protecting and improving the public's health. We're gathering information on health and tobacco from selected people across the United States. Your phone number has been chosen randomly from a list of all telephone numbers in the US.

Are you a member of this household and at least 18 years old?

1. YES  CONTINUE

2. NO, TOO BUSY, NOT A GOOD TIME, OR REQUESTS APPOINTMENT CALLBACK OR APPOINTMENT

LPHONEUSE

/ASK IF L1 LINTRO1 EQ 1/

L2. Is this phone number used for…

1. Home use

2. Home and business use, or

3. Business use only  THANK AND END CALL

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 Reports Clearance Officer, 1600 Clifton Road, MS-74, Atlanta, GA 30333, ATTN: PRA (0920-0828).

Additional Information:

TRAINING: Don’t Know/Not sure and Refused are not allowed. If the person answering the phone doesn’t know the answers to the questions, attempt to get someone else to the phone and re-read the introductory text. If no one is available, schedule a callback. If the person answering the phone refuses to answer these questions or breaks off a call, code the Screener as a Refusal or other appropriate disposition. This is true throughout the Screener.

Home use includes a phone which serves a house, apartment, or condominium. If the phone serves a residence such as barracks, dorm, or nursing home, code as business use only.

lnoadult

/ASK IF L2 LPHONEUSE EQ (1,2)/

[RANGE: 1-76,77,88,99]

[USE 76 FOR 76 OR MORE PEOPLE]

L3. The CDC uses the data collected by this study to develop more effective public health programs. Your household’s participation is voluntary and important to the success of this study.

First, I need to randomly select one adult who lives in your household to be interviewed. Including yourself, how many adults age 18 and older currently live in this household? Please do not include students living away at school.

[IF NEEDED: Include adults who think of this household as their primary place of residence. Include adults who usually stay in the household but are temporarily away on business, vacation, or in a hospital.]

_ _. Number of adults  If L3 Lnoadult=1 OR (L3 LNOADULT EQ 2 AND RESPONDENT ON PHONE IS SELECTED), Go to L4 LSELADULT1; ELSE IF L3 LNOADULT=2 AND RESPONDENT ON PHONE IS NOT SELECTED; ELSE IF L3 LNOADULT > 2 AND RESPONDENT ON PHONE IS NOT SELECTED, GO TO L6 LSELADULT3

lSELadult1

/ASK IF L3 LNOADULT=1 OR (LNOADULT=2 AND RESPONDENT ON PHONE IS SELECTED)/

L4. You have been selected to participate in this interview. Please tell me just your first name.

[IF FIRST NAME REFUSED OR DON’T KNOW, ASK FOR INITIALS, AGE/SEX, RELATION OR OTHER IDENTIFYING INFORMATION.]

[PROBE: We need some way to ask for you if we need to call back.]

______________ first name or other identifier

IF SELECTED RESPONDENT PROVIDES IDENTIFIER, CONTINUE WITH:

We're gathering information on health and tobacco from selected people across the United States. Your phone number has been chosen randomly from a list of all telephone numbers in the U.S.

Your participation in the study is voluntary. You don’t have to answer any question you don’t want to, and you can end the interview at any time. I won't ask for your full name, address, or other personal information that can identify you.

The interview takes about 15 to 25 minutes to complete, depending on your situation.

There are no known risks to you for taking part in this interview. There are no direct benefits to you for taking part in this interview, but your answers are important and will help the CDC better understand health issues and plan health programs. Your answers will be maintained in a secure manner. Any information that might identify you, such as your telephone number, will never be linked to your answers and will not appear in any written reports or publications.

If you have any questions about this survey, I will provide a telephone number for you to call to get more information.

This call may be monitored for quality assurance.

GO TO L8 LSELRESMF

LSELADULT2

/ASK IF LNOADULT=2 AND RESPONDENT ON PHONE IS NOT SELECTED

L5. The other adult in your household has been selected to participate in this interview. Please tell me just the first name of the other adult in the household.

[IF FIRST NAME REFUSED OR DON’T KNOW, ASK FOR INITIALS, AGE/SEX, RELATION OR OTHER IDENTIFYING INFORMATION.]

[PROBE: We need some way to ask this person if we need to call back.]

______________ first name or other identifier

GO TO L7 LINTRO2

LSELADULT3

/ASK IF LNOADULT ≥ 3 AND RESPONDENT ON PHONE IS NOT SELECTED

L6. Please tell me just the first name of the adult in the household, other than yourself, who will have the next birthday.

[IF NEEDED: We are only interviewing one adult in each household and asking this question helps the computer decide which person that should be.] [IF FIRST NAME REFUSED OR DON’T KNOW, ASK FOR INITIALS, AGE/SEX, RELATION OR OTHER IDENTIFYING INFORMATION.]

[PROBE: We need some way to ask this person if we need to call back.]

______________ first name or other identifier

GO TO L7 LINTRO2

lintro2

/ASK IF L5 LSELADULT2 IS NOT BLANK OR L6 LSELADULT3 IS NOT BLANK /

L7. May I speak with [IDENTIFIER OF SELECTED RESPONDENT]?

[IF PERSON ON THE PHONE IS NOT THE SELECTED RESPONDENT AND ASKS “Who’s calling?”: SAY: Hello, my name is _________. I'm calling for the CDC, the Centers for Disease Control and Prevention. We're gathering information on health and tobacco from selected people across the U.S.]

TRAINING: READ THE TEXT ONLY IF THE PERSON WHO ANSWERS THE PHONE ASKS, “Who’s calling?” WHEN THE SELECTED RESPONDENT COMES TO THE PHONE, ENTER 1 AND READ THE INTRODUCTION THAT APPEARS ON THE NEXT SCREEN. THIS IS IMPORTANT BECAUSE THE SELECTED RESPONDENT MAY NEED TO HEAR OTHER INTRODUCTORY TEXT THAT SHOULD NOT BE READ TO JUST ANYONE ANSWERING THE PHONE

IF SELECTED RESPONDENT COMES TO THE PHONE: Hello, my name is ___________. I'm calling for the CDC, the Centers for Disease Control and Prevention. The CDC is a federal agency charged with protecting and improving the public's health.

We're gathering information on health and tobacco from selected people across the United States. Your phone number has been chosen randomly from a list of all telephone numbers in the U.S.

Your participation in this study is voluntary. You don’t have to answer any question you don’t want to, and you can end the interview at any time. I won't ask for your full name, address, or other personal information that can identify you.

The interview takes about 15 to 25 minutes to complete, depending on your situation.

There are no known risks to you for taking part in this interview. There are no direct benefits to you for taking part in this interview, but your answers are important and will help the CDC better understand health issues and plan health programs. Your answers will be maintained in a secure manner. Any information that might identify you, such as your telephone number, will never be linked to your answers and will not appear in any written reports or publications.

If you have any questions about this survey, I will provide a telephone number for you to call to get more information.

This call may be monitored for quality assurance.

1. CONTINUE

lSELRESmf

/ASK IF L4 LSELADULT1 IS NOT BLANK OR L7 LINTRO2=1/

L8. IS THE SELECTED RESPONDENT MALE OR FEMALE?

INTERVIEWER: Ask only if necessary.

Are you male or female?]

1. Male

2. Female

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