OMB
Control Number: 0925-0663
Expiration Date: 11/30/2015
This screener will be administered in Spanish. It is provided in English for review purposes only.
Westat, a research firm located in Rockville, MD, is doing research for the National Institutes of Health in partnership with the Food and Drug Administration for a study about tobacco use. If you are eligible and you agree to participate, we will give you $40 as a thank you to complete an in-person interview that should last about an hour. In order to find out if you are eligible to be interviewed, I need to ask you a few questions. Your answers to these questions will only be used to determine whether you are eligible to participate in the interview. Some of these questions are personal. We will keep your answers confidential, but if you would prefer not to answer any of the questions, just let me know.
May I go ahead?
YES
NO TERMINATE
How old are you?
Under 18 INELIGIBLE
_________
How many individual interviews or focus groups have you participated in at survey research companies in the past year?
0
1-2
MORE THAN 2 TERMINATE
When you are at home, would you usually speak…
(READ
THE LIST. SELECT ONLY ONE RESONSE)
Only English TERMINATE
Mostly English, a little of Spanish TERMINATE
Half English, half Spanish
Mostly Spanish, a little English, or
Only Spanish?
DOES NOT KNOW TERMINATE
I’d like to learn more about how often you use the Spanish language. How often do you speak Spanish to friends, relatives, or people in the community? Would you say…
Most of the time
On a regular basis
Some of the time
Not very often, or TERMINATE
Never? TERMINATE
How often do you read Spanish publications, such as newspapers or magazines? Would you say…
Most of the time
On a regular basis
Some of the time
Not very often, or TERMINATE
Never? TERMINATE
How often do you read listen to Spanish-speaking radio or watch Spanish TV? Would you say…
Most of the time
On a regular basis
Some of the time
Not very often, or TERMINATE
Never? TERMINATE
Which of the following tobacco products do you use now?
Cigarettes
Cigars
or cigarillos
Examples:
Black & Milds, Swisher Sweets, Dutch Masters, White Owl,
Phillies Blunts
Chewing
tobacco, snuff, or dip
Examples:
Skoal, Cophenhagen, Grizzly, Levi Garrett, Red Man, Day’s Work
Pipe
Hookah
Snus
Pronounced
to rhyme with goose
Dissolvable
tobacco product
Examples:
Ariva, Stonewall, Camel Orbs, Camel Sticks, Camel Strips
E-cigarettes (i.e., electronic cigarettes)
Other
electronic products
Examples:
E-Cigars, E-Hookahs, or any other electronic version of a tobacco
product
Are you male or female?
male
female
Are you Hispanic, Latino, Latina, or of Spanish origin?
YES
NO
What is your race? CHOOSE ALL THAT APPLY.
AMERICAN INDIAN OR ALASKA NATIVE
ASIAN
BLACK OR AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
WHITE
What is the highest level of education you have completed?
Less than high school
Completed 12th grade/high school graduate
Some college/2-year college/technical school
College degree
Graduate or professional school
if ineligible
Thank you very much for your interest, but you are not eligible for this study. Thank you very much for your time. We will destroy the information you have provided.
if
eligible
Thank you for answering all my questions. We will contact you if you are selected to participate. Can I have your name, address, phone number and/or email so that we can get in touch with you?
COLLECT RESPONDENT NAME, ADDRESS, AND PHONE NUMBER/EMAIL.
Name: _____________________________________________________________
Child’s Name (if applicable): ____________________________________________
Address: _____________________________________________________________
City: _________________________________ State: ______ Zip Code: __________
Phone: _________________________________
Email: _________________________________
Public reporting burden for this collection of information is estimated to average 10 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 (0925-0663). Do not return the completed form to this address.
PATH
Phase 5 Recruitment Screener
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |