Form 1 Screener

SFTXT – Attachment 9: Screener Questionnaire & Screenshots

Word Questions Pages 2 to 5

Screenshots Pages 6 to 14

OMB No.: 0925-XXXX

Expiration Date:  xx/xx/20xx

Collection of this information is authorized by The Public Health Service Act, Section 410 (285) and Section 412 (285a-1). Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private to the extent provided by law.  Names and other identifiers will not appear in any report of the study. Information provided will be combined for all study participants and reported as summaries.  In order to provide feedback on its tobacco cessation services, the National Cancer Institute has asked you to complete this voluntary survey.

Public reporting burden for this collection of information is estimated to average 5 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-XXXX). Do not return the completed form to

[ON NEXT WEBPAGE:]

Screener Introduction [text to go on study website]

You are invited to be part of a study to understand how to help young adult smokers quit smoking cigarettes. This 10-question survey will help us determine whether you are eligible to participate in the QuitTXT study.

Click ‘Next’ to start the short survey. [Takes respondent to screener page]

this address.

[ON NEXT WEBPAGE:]

1. How did you find out about this study? (Please select all that apply)

1. Craig’s list

2. Facebook

3. Email invitation

4. Friend or family member

5. Other ______________________ (please specify)

2. How old are you?

If Q2 [AGE_S2] = 18-29, GO TO Q3.

If Q2 [AGE_S2] <18 OR >29, GO TO INELIGIBLE STATEMENT.

3. Do you live in the United States?

   1. Yes

   2. No

IF Q3 [US_RESIDENT_S3] = YES, GO TO Q4.

IF Q3 [US_RESIDENT_S3] = NO, GO TO INELIGIBLE STATEMENT.

4. Do you currently smoke?

   1. Yes

   2. No

IF Q4 [SMOKENOW_S4] = YES, GO TO Q5.

IF Q4 [SMOKENOW_S4] = NO, GO TO INELIGIBLE STATEMENT.

5. In the past 30 days, how many days have you smoked?

Enter a number 0-30: ___ days [if 0-4 days, exclude]

IF Q5 [SMOKE_LAST_S5] = >4 GO TO Q6. IF Q5 [SMOKE_LAST_S5] <5, GO TO INELIGIBLE STATEMENT.

6. Overall, on a scale from 1 to 5 where 1 is NOT AT ALL interested and 5 is EXTREMELY interested, how interested are you in stopping smoking in the next 30 days?

1. Not at all interested

2. Mildly interested

3. Moderately interested

4. Very interested

5. Extremely interested

IF Q6 [INTEREST_QUIT_S6] = NOT AT ALL INTERESTED OR REFUSED, GO TO INELIGIBLE STATEMENT.

IF Q6 [INTEREST_QUIT_S6] = MILDLY, MODERATELY, VERY, OR EXTREMELY INTERESTED, GO TO Q7.

7. Are you currently involved in a quit smoking treatment (e.g., regularly taking quit smoking medication or regularly getting quit smoking counseling)?

   1. Yes

   2. No

IF Q7 [QUIT_TX_S7] = YES, GO TO INELIGIBLE STATEMENT.

IF Q7 [QUIT_TX_S7] = NO, GO TO Q8.

8. Do you have an email address that allows you to send and receive emails regularly?

   1. Yes

   2. No

   3. Don’t know

IF Q8 [EMAIL_S8] = YES, GO TO Q9.

IF Q8 [EMAIL_S8] = NO, DK, GO TO INELIGIBLE STATEMENT.

9. Are you able to receive unlimited text messages on your cell phone?

1. Yes

2. No

3. I don’t have a cell phone

4. Don’t know

IF Q9 [UNLIM_TXT_S9] = YES, GO TO Q10.

IF Q9 [UNLIM_TXT_S9] = N0, GOT TO 9A. IF “I DON’T HAVE A CELL PHONE” OR “DON’T KNOW”, GO TO INELIGIBLE STATEMENT.

9A. You may receive up to 130 text messages over 8 weeks. Regular data charges to your phone will apply. Is this okay with you?

1. Yes

2. No [exclude]

IF Q9A [130TXT_S9A] = YES, GO TO Q10.

IF Q9A [130TXT_S9A] = NO, GO TO INELIGIBLE STATEMENT.

10. Are any other members in your household participating in this evaluation?

1. Yes

2. No

3. Not sure

IF Q10 [OTHER_HH_S10] = YES, GO TO INELIGIBLE STATEMENT.

GO TO Q10 [OTHER_HH_S10] = NO OR NOT SURE, INCLUDE AS ELIGIBLE.

Thank you for completing this short survey. Please click “Next” to find out if you are eligible to participate in the QuitTXT Study.

Page 15