Evaluation of the National Tobacco Prevention and Contro

[DISPLAY]

Form Approved

OMB No. 0920-0923

Exp. Date 04/30/2014

Evaluation of the National Tobacco Prevention and Control Public Education Screening Questionnaire

Public reporting burden of this collection of information is estimated to average 2 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 CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0923).

[IF ABS, ASK S1_1]

[IF SAMPLE = KP OR SSI, GO TO A1]:

S1a. Welcome to the CDC Health Survey! Your opinion counts! Please try to answer all questions to the best of your ability. Your answers will be kept private. We have a few qualifying questions about you and other members of your household.

If you or another member of your household is selected and completes our one-time 25-minute interview, the respondent will be sent [$ AMOUNT] as our way of saying “thank you.”

First, are you 18 years old or older?

1. Yes

2. No

G12. In what state do you live?

_________Pull Down List of States + DC

G13. What county do you live in?

_________Pull Down List of Counties

G14. What is the zip code where you live?

You told us you live in zip code [FILL ZIP]. Is this correct?

1. Yes

2. No

S1. Including yourself, how many adults 18 or older are currently living in your household?

1. 1

2. 2

3. 3

4. 4

5. 5 or more

6. None, no adults live here

A1. Next, we’d like some brief information about you.

How old are you (in years)?

____________ # Years

S2_2. Are you….?

1. Male

2. Female

A2. Have you smoked at least 100 cigarettes in your entire life?

1. Yes

2. No

A3. Do you now smoke cigarettes every day, some days, or not at all?

1. I smoke every day

2. I smoke on some days

3. I do not smoke at all

S2. Next, we’d like some brief information about [IF S1=1: the adult / IF S1=2-5: each adult] in the household. What is the age and gender of the adult and has the adult smoked at least 100 cigarettes in his or her entire lifetime?

	2A. Age (in number of years)	2B. Gender	2C. Smoked at least 100 cigarettes in entire lifetime?
Adult 1		O Male O Female	O Yes O No
Adult 2		O Male O Female	O Yes O No
Adult 3		O Male O Female	O Yes O No
Adult 4		O Male O Female	O Yes O No
Adult 5		O Male O Female	O Yes O No

S3. For each person who smoked 100 or more cigarettes in his/her lifetime, does [he/she] smoke every day, some days, or not at all?

1. Every day

2. Some days

3. Not at all

[IF NOT SELECTED, DISPLAY]

Thank you for your participation today. Your answers to this short survey were very valuable to us. As of this time, all the longer surveys you could participate in have been completed for us so you and your household have not been selected for our study. Thanks again for your contribution to this important research.

S6. Good news! The [AGE] year old [man/woman] in your household has been selected for our study, which takes about 25 minutes to complete for a [$ AMOUNT] reward. Are you that person?

1. Yes

2. No

[IF S6=1, ASK S6b]

S6b. Welcome to the CDC Health Survey! Thank you for making sure your opinion counts!

Please try to answer all questions to the best of your ability. Your answers will be kept anonymous.

Based on some information provided earlier about your household, the [AGE] year old [man/woman] in your household has been selected for our study. Are you that person?

1. Yes

2. No

[IF S6b=1, SHOW]:

Great! Please note that the survey takes about 25 minutes to complete and you will be sent [$ AMOUNT] once the survey is completed as our way of saying “thank you.”

A1. Thank you for agreeing to take this survey. Our first few questions are primarily for classification purposes and they enable us to select the questions to ask you later in the survey. They will also help us properly analyze responses to this survey.

What is your age?

_______ years old

[TERMINATE IF A1<18]

A2. Have you smoked at least 100 cigarettes in your entire life?

1. Yes [GO TO A3]

2. No [GO TO NONSMOKER SURVEY]

A3. Do you now smoke cigarettes every day, some days, or not at all?

1. I smoke every day [GO TO SMOKER SURVEY]

2. I smoke on some days [GO TO SMOKER SURVEY]

3. I do not smoke at all [GO TO NONSMOKER SURVEY]

[IF SAMPLE=KP OR SSI, ASK S1-G14]

S1. Including yourself, how many adults 18 or older are currently living in your household?

1. 1

2. 2

3. 3

4. 4

5. 5 or more

6. None, no adults live here

G12. In what state do you live?

_________Pull Down List of States + DC

G13. What county do you live in?

_________Pull Down List of Counties

G14. What is the zip code where you live?

G14b. You told us you live in zip code [FILL ZIP]. Is this correct?

3. Yes

4. No

INTRODUCTION

According to your previous responses, you qualify to participate in a survey that will take about 25 minutes to complete. You will be asked various questions about your experiences with tobacco and television ads about smoking as well as a few questions about your background. The goal of this survey, which will include approximately 5,000 individuals nationwide, is to provide more in-depth analysis of mass media efforts and smoker’s reactions to television ads.

Your responses will be maintained in a secure manner and no personal identification information will be passed on to the sponsors of this study. In addition, your name or other personal information will never be associated with your responses. The data collected for this research study will be combined with that of all participants before it is analyzed.

There are no physical risks involved in participating in this study; however, it is possible that you could find some of the questions to be sensitive. If you find a question during the survey to be too personal, you may choose not to answer the question. Your participation is strictly voluntary and you may terminate your participation at any time. The benefit of participating in this study is to assist the sponsor in determining a nationwide estimate of awareness of an important media campaign. You will be awarded 15,000 bonus points credited to your KnowledgePanel account for completing this study.

This survey is being conducted on behalf of the Centers for Disease Control and Prevention (www.cdc.gov) and RTI International (www.rti.org), a non-profit research organization that conducts studies on many types of health and social issues. If you have any questions about this study, you can contact GfK Panel Relations at 1-800-782-6899 and you will be directed to the appropriate researchers. If you have any questions about your rights as a study participant, you can contact RTI’s Human Research Protections Office by email at [email protected], or by phone at 1-866-214-2043 (a toll-free number). Please print or save a copy of this document for your records.

I have read and understand the information provided above and the study purpose and procedures are clear to me.

1. Yes, I agree to participate in this study.

2. No, I do not wish to participate in this study.

[terminate if no or skip]

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