2 Screener

Attachment C - SFW Customer Satisfaction Study

03.10.2014

Screener Survey

OMB No.: 0925-0046

Expiration Date:  05/31/2016

Collection of this information is authorized by The Public Health Service Act, Section 410 (285) and Section 412 (285a-1). 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 under the Privacy Act of 1974, as amended, 5 U.S.C. 552a (SORN #09-25-0156). 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.  You are being contacted by the National Cancer Institute to provide feedback on its tobacco cessation website.

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 (0925-0046). Do not return the completed form to this address.

Screener Survey – Smokefree Women Customer Satisfaction Study

You are invited to be part of a study to help improve quit smoking resources for women. This survey will help us determine whether you are eligible to participate in the Smokefree Women Customer Satisfaction Study.

The survey will take about 5 minutes to complete. Thank you for taking the time to complete this survey.

1. How old are you? ____ years old [input box, capable of capturing 2 digits]

If input 0-17, exclude

2. What is your sex?

   1. Male

   2. Female

If answer a. Male, exclude

3. Do you have an email address that allows you to send and receive emails regularly (daily or weekly)?

   1. Yes

   2. No

   3. Don’t know

If answer b. No or C. Don’t know, exclude

4. Are you able to access the internet regularly (daily or weekly)?

   1. Yes

   2. No

If answer b. No, exclude

5. Do you currently smoke?

   1. Yes

   2. No

If answer b. No, exclude

6. In the past 30 days, how many days have you smoked? Enter a number 0-30: ____ days. If you’re not sure, give your best guess. [input box, capable of capturing 4 digits]

If input 0-4, exclude

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

[Next button]

Ineligible Message [will be shown as a pop-up or new page]

For individuals who are not eligible due to one of their answers from the screener Q 1-6. Once it has been determined that they are ineligible, they are immediately told they are ineligible. Below is the message they will receive.

Thank you for your interest in this study. We are sorry to say that you are not eligible to participate in the study. Please do not try and take the survey again. You won’t be eligible to participate. Please visit women.smokefree.gov or smokefree.gov for quit smoking help.

If you have questions, please contact the study team at:

• Email: [email protected]

• Phone: XXX-XXX-XXXX

Eligible Message [will be shown as a pop-up or new page]

For individuals who are eligible due to their answers from the screener Q 1-6. Once it has been determined that they are eligible, they will receive the prompt below and immediately continue to the Initial Survey

You are eligible to participate in the study.

This study will last 4 weeks total. As a thank you for participating, you will be entered into a lottery to receive a $20 in Amazon e-gift card at the end of the study. You must take part in the full 4 week study and complete the Customer Satisfaction Survey to be entered into the lottery.

If you would like to participate in the study click the “Next” button and complete the Initial Survey to begin.

[Next]

If you have questions, please contact the study team at:

• Email: [email protected]

• Phone: XXX-XXX-XXXX

Screener Survey Screenshots

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