A-3 Recruitment Screener

O MB Control Number: 0925-0663
Expiration Date: 11/30/2015

PATH Wave 4 Focus Groups

Youth Recruitment Screener

Parent or Guardian:

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. We are recruiting youth between the ages of 12 and 17. We will interview both youth who use tobacco and youth who do not use tobacco.

If your child is eligible and you agree to allow them to participate, we will give them $25 as a thank you for completing an in-person interview that should last about an hour. You will need to attend the beginning of the interview in order to give written permission for your child to participate, but you will be asked to leave the room during the interview itself. You will receive $10 for any travel expenses.

In order to find out if your child is eligible to be interviewed, I need to ask them a few questions. Their answers to these questions will only be used to determine whether they are eligible to participate in the interview. Some of these questions are personal. We will keep your child’s answers confidential, but they may choose not to answer any questions if they would prefer not to.

1. May I ask your child a few questions to determine if they are eligible to participate in this study?

• YES  ASK TO SPEAK WITH YOUTH

• NO TERMINATE

Youth:

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 $25 as a thank you to complete an in-person interview that should last about an hour. Your parent or guardian will need to attend the beginning of the interview in order to give written permission for you to participate, but they will be asked to leave the room during the interview itself.

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.

2. May I go ahead?

• YES

• NO TERMINATE

3. How old are you?

• Under 12/over 18 INELIGIBLE

• _________

4. What grade are you currently in?

• _________

5. Do you currently smoke cigarettes?

• YES

• NO

6. Do you currently smoke hookah?

• YES

• NO

7. Do you currently smoke or use other tobacco products such as cigars, cigarillos, chewing tobacco, pipe, or snus?

• YES

• NO

8. Do you currently use electronic nicotine products, such as e-cigarettes, e-pipes, e-hookahs, or e-cigars?

• YES

• NO

9. Do you use social media, such as Facebook, Twitter, Instagram, Pinterest, or Snapchat?

• Yes

• no

10. Have you ever used an app related to tobacco products, e-cigarettes, or other electronic nicotine products?

• Yes

• no

11. Are you male or female?

• male

• female

12. Are you Hispanic, Latino, Latina, or of Spanish origin?

• YES

• NO

13. 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

if ineligible

Thank you 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: _____________________________________________________________

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.