National Adult Tobacco Survey Screener

National Adult Tobacco Survey

H-2 Cell Phone Screener

National Adult Tobacco Survey Screener

OMB: 0920-0828

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Form Approved

OMB No. 0920-0828

Exp. Date xx/xx/xxxx

H-2. Cell Phone Screener

TRAINING: Don’t Know/Not sure and Refused are not allowed. If the person answering the phone refuses to answer these questions or breaks off a call, or if the phone is not a cell phone, code the Screener as a Refusal or other appropriate disposition. This is true throughout the Screener.

CPintro

/ASK ALL/

INTERVIEWER: PLEASE READ SLOWLY AND DISTINCTLY

C1. 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. Please let me know if you are currently driving a car or doing any activity that requires your full attention, so I can call you back at a later time.

[END CALL IMMEDIATELY IF R IS DRIVING OR DOING AN ACTIVITY AND SET APPOINTMENT.]

We're gathering information on health and tobacco from selected cell phone users across the United States. Your phone number has been chosen randomly from a list of all cell phone numbers in the US. It will take about 2 minutes to see if you qualify for the study.

Are you at least 18 years old?

1. YES CONTINUE

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


Public reporting burden of this collection of information is estimated to average 1 minute 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).

CPpHONEUSE

/ASK IF C1 CPINTRO EQ 1/

C2. Is this phone number used for…

1. Personal use

2. Personal and business use, or

3. Business use only THANK AND END CALL


CPname

/ASK IF C2 CPPHONEUSE EQ (1,2)

/LENGTH OF CPNAME = 20/

C3. To make sure that we talk to you if we have to call you back, please give us a first name to ask for. You can make up a name if you like.

CPlandline

/ASK IF C2 CPPHONEUSE EQ (1,2)

C4. In your home, is a cell phone the only way you can be reached by telephone?

1. YES GO TO C6 CPPRIVRES

2. NO THANK AND END CALL


CPprivres

/ASK IF C4 CPLANDLINE EQ 1/

C6. Do you live in a house, an apartment, a condominium, or other type of private residence?

interviewer: if respondent is unsure about WHAT a “private residence” IS, read:

Examples of places where people live that are not private residences are barracks, dormitories, and nursing homes. Is the place where you live more like a house, an apartment or condominium, or more like a barracks, a dormitory, or a nursing home?

1. YES

2. NO THANK AND END CALL



CPconfidential

/ASK IF C6 CPprivres=1/

C7. You are eligible to be interviewed.

You have been selected to participate in this interview.

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.

Is respondent continuing with the interview?

1. YES






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