Form 2h Parent Interview/Field Test

Population Assessment of Tobacco and Health (PATH) Study (NIDA)

Attachment 2h
PATH Study Data Collection Instruments:
Parent Interview
July 23, 2012

PATH
Parent Interview
Version 6.1

Number of
questions

Section
All

PATH
Parent Interview

57

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Parent Interview
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OMB Control Number: 0925-XXXX

Expiration Date: XX/XX/XXXX

Public reporting burden for this collection of information is estimated to average 19 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 this address.

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Box P1

Screen ID:

DISPLAY THE FOLLOWING FOR THE INTERVIEWER:
Parent name: {PARENT NAME/AGE/SEX}
Children associated with this parent in the household screener:
Sampled youth: {CHILD NAME/AGE/SEX}, [LIST UP TO 6 SAMPLED YOUTH]
Shadow sample child: {CHILD NAME/AGE/SEX}
Box P2

Screen ID:

PROGRAM: Repeat the PT0001 and PT0002 (as appropriate) sequence for each sampled youth
associated with this parent in the household screener. After questions have been asked about all
sampled youth, ask the specified questions about the shadow sampled youth (PT0001).
PATH ID:

PT0001

Screen ID:

What is your relationship to {CHILD’S FIRST NAME/AGE/SEX}?
1
2
3
4
5
6
7
8
9
10
11
12
91
92
-8
-7

BIOLOGICAL MOTHER
BIOLOGICAL FATHER
ADOPTED MOTHER
ADOPTED FATHER
STEP MOTHER
STEP FATHER
FOSTER MOTHER
FOSTER FATHER
GRANDMOTHER
GRANDFATHER
AUNT
UNCLE
OTHER RELATIVE
NON RELATIVE
DON’T KNOW
REFUSED

(SPECIFY) ________________
(SPECIFY)________________

IF ASKING ABOUT A SAMPLED YOUTH, GO TO PT0002
IF ASKING ABOUT A SHADOW SAMPLE CHILD, GO TO BOX P4
ASK: Parent/guardian of sampled youth, about each sampled youth and each shadow sample child

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PATH ID:

PT0002

Screen ID:

What is your spouse or partner’s relationship to {CHILD’S FIRST NAME/AGE/SEX}?
1
2
3
4
5
6
7
8
9
10
11
12
13
91
92
-8
-7

I do not have a spouse or partner
BIOLOGICAL MOTHER
BIOLOGICAL FATHER
ADOPTED MOTHER
ADOPTED FATHER
STEP MOTHER
STEP FATHER
FOSTER MOTHER
FOSTER FATHER
GRANDMOTHER
GRANDFATHER
AUNT
UNCLE
OTHER RELATIVE
NON RELATIVE
DON’T KNOW
REFUSED

(SPECIFY)________________
(SPECIFY)________________

ASK: Parent/guardian of sampled youth.
PATH ID:

PT0009

Screen ID:

Does {CHILD’S FIRST NAME/AGE/SEX} have a set time that {he/she} needs to be home on school
nights?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.
PATH ID:

PT0011

Screen ID:

Does {CHILD’S FIRST NAME/AGE/SEX} have a set time that {he/she} needs to be home on weekend
nights?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.

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PATH ID:

PT0019

Screen ID:

How would you describe how {CHILD’S FIRST NAME/AGE/SEX} has performed at school in the past 12
months?
Would you say {CHILD’S FIRST NAME/AGE/SEX}’s grades are..
1
2
3
4
5
6
-8
-7

Straight A’s
Mostly A’s
Mostly B’s
Mostly C’s
Mostly D’s, or
Mostly F’s?
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.
PATH ID:

PT0030

Screen ID:

How often during the past 12 months did {CHILD’S FIRST NAME/AGE/SEX} miss school due to illness?
1
2
3
4
5
-8
-7

Never
Rarely
Sometimes
Often
Very often
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.
PATH ID:

PT0021

Screen ID:

As far as you know, has {CHILD’S FIRST NAME/AGE/SEX} ever smoked a cigarette or used other
tobacco products, such as a pipe, smokeless tobacco, chew, dip, snus, dissolvable products, ecigarettes, or hookah? Would you say…
1
2
3
4
-8
-7

You know that {she/he} has
You strongly suspect {she/he} has,
You don’t think {she/he} has or
You are confident {she/he} has not?
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.

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PATH ID:

PX0001

Screen ID:

What are the rules or restrictions in your household about using any type of tobacco? Would you say…
1
2
3
4
-8
-7

Tobacco use is completely banned
Tobacco use is generally banned with few exceptions
Tobacco use is allowed in some rooms only, or
There are no restrictions on tobacco use?
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.
PATH ID:

PT0007

Screen ID:

What is {CHILD’S FIRST NAME/AGE/SEX’s} current height?
I___I I___I___I
FEET INCHES
DON’T KNOW
REFUSED

1
-8
-7

ASK: Parent/guardian of sampled youth.
PATH ID:

PT0008

Screen ID:

What is {CHILD’S FIRST NAME/AGE/SEX’s} current weight?
I___I___I____I
POUNDS
DON’T KNOW
REFUSED

1
-8
-7

ASK: Parent/guardian of sampled youth.
PATH ID:

PT0035

Screen ID:

In general, would you say {CHILD’S FIRST NAME/AGE/SEX} health is…
1
2
3
4
5
-8
-7

Poor
Fair
Good
Very good
Excellent
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.

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PATH ID:

PT0022

Screen ID:

In the past 12 months, what medications has {CHILD’S FIRST NAME/AGE/SEX} taken regularly?
Choose all that apply.
2
3
4
-8
-7

ADHD medications - for example: Adderall, Ritalin, Concerta, or Strattera
Asthma medications (pills or inhalers)
Other medications
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.
GO TO: IF RESPONDENT SELECTED YES FOR ASTHMA MEDICATIONS, GO TO PT0036.
OTHERWISE GO TO PT0031.
PATH ID:

PT0036

Screen ID:

In the past 12 months, which of the following medications did {CHILD’S FIRST NAME/AGE/SEX}
regularly take for asthma? Choose all that apply.
1
2
3
4
5
-8
-7

Quick-relief inhaler - for example: albuterol (ProAir, Ventolin, Xopenex)
Controller or long-acting inhaler including steroid inhaler – for example:
beclomethasone (Qvar), fluticasone (Flovent), salmeterol (Serevent), or a
combination inhaler (Advair)
Other controlling medication – for example: montelukast (Singulair), zafirlukast
(Accolate), theophylline
Oral or injected steroid medication – for example: prednisone, prednisolone
(Orapred), dexamethasone (Decadron)
Other asthma medication
DON’T KNOW
REFUSED

ASK: If sampled youth took medications for asthma (PT0022=3)
PATH ID:

PT0031

Screen ID:

Has {CHILD’S FIRST NAME/AGE/SEX} ever been told by a doctor or a health professional that {he/she}
has any of the following? Choose all that apply.
1
2
3
4
5
-8
-7

Asthma
High blood pressure
Diabetes
A cholesterol problem
None of the above
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.

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PATH ID:

PT0033

Screen ID:

In the past 12 months, has {CHILD’S FIRST NAME/AGE/SEX} been told by a doctor or a health
professional that [he/she] has any of the following? Choose all that apply.
1
2
3
-8
-7

Bronchitis, pneumonia, or chronic cough
Dental health issues or bad breath
None of the above
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.
PATH ID:

PX0302

Screen ID:

In the past 12 months, has {CHILD’S FIRST NAME/AGE/SEX} visited an emergency room or urgent care
center for a health problem?
1
2
-8
-7

Yes
No
DON’T KNOW
REFUSED

GO TO PT0024
GO TO PT0024
GO TO PT0024

ASK: Parent/guardian of sampled youth.
PATH ID:

PT0034

Screen ID:

How many visits to the emergency room or urgent care has {CHILD’S FIRST NAME/AGE/SEX} made in
the past 12 months?
|__|__|__|
1
VISITS
-8
DON’T KNOW
-7
REFUSED
ASK: Parent/guardian of sampled youth who has visited an emergency room or urgent care in the past
12 months (PX0302=1).
GO TO: If PT0034 IN (0, DK, RF), go to PT0024
Else go to PT0037
PATH ID:

PT0037

Screen ID:

Why did {CHILD’S FIRST NAME/AGE/SEX} go to the emergency room or urgent care in the past 12
months? Choose all that apply.
1

Asthma attack or other respiratory illness

2

Accident or trauma

3

Another medical condition

-8
-7

DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth who have been to the emergency room or urgent care at least
one time in the past 12 months (PT0034>0).

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PATH ID:

PT0024

Screen ID:

Is {CHILD’S FIRST NAME/AGE/SEX} limited in the ability to go to school, do chores around the house,
or work at a job because of an impairment or a physical or mental health problem?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

GO TO PT0003
GO TO PT0003
GO TO PT0003

ASK: Parent/guardian of sampled youth.
PATH ID:

PT0025

Screen ID:

Which activities is {CHILD’S FIRST NAME/AGE/SEX} limited in doing because of an impairment or a
physical or mental health problem? Choose all that apply.
1
2
3
-8
-7

Going to school
Doing chores
Working at a job
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth whose child has some limited abilities (PT0024=1).
PATH ID:

PT0003

Screen ID:

Does {CHILD’S FIRST NAME/AGE/SEX} have another parent who lives somewhere else?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

GO TO PM0001
GO TO PM0001
GO TO PM0001

ASK: Parent/guardian of sampled youth.
PATH ID:

PT0006

Screen ID:

How often does {CHILD’S FIRST NAME/AGE/SEX} stay there? Would you say.
1
2
3
91
-8
-7

Less than half the time
About half the time, or
More than half the time?
OTHER
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth if that child has another parent who lives somewhere else
(PT0003=1).

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PATH ID:

PT0005

Screen ID:

Do you think cigarettes or tobacco might be available to {CHILD’S FIRST NAME/AGE/SEX} when
{he/she} is at the other parent’s home?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth if that child has another parent who lives somewhere else
(PT0003=1).
PATH ID:

PM0001

Screen ID:

These next few questions are about you.
What is the highest grade or year of school that you completed?
1
2
3
4
5
6
7
8
9
10
11
12
13
-8
-7

UP TO 8TH GRADE
9TH TO 11TH GRADE
12TH GRADE BUT NO DIPLOMA
HIGH SCHOOL DIPLOMA/EQUIVALENT
VOC/TECH PROGRAM AFTER HS BUT NO VOC/TECH DIPLOMA
VOC/TECH DIPLOMA AFTER HS
SOME COLLEGE BUT NO DEGREE
ASSOCIATE’S DEGREE (A.A., A.S.)
BACHELOR’S DEGREE (B.A., B.S.)
SOME GRADUATE OR PROFESSIONAL SCHOOL BUT NO DEGREE
MASTER’S DEGREE (M.A., M.S.)
DOCTORATE DEGREE (PH.D., ED.D)
PROFESSIONAL DEGREE BEYOND BACHELOR’S (MEDICINE/MD;
DENTISTRY/DDS; LAW/JD/LLB; ETC)
DON’T KNOW
REFUSED

ASK: Parent/guardian of sampled youth.
PROGRAM:
Ask questions PN0001 to PN0003 only of parents/guardians who are not the Household Screener
Respondent and who have not been sampled for the Adult survey. All respondents who are the
Household Screener Respondent or who have been sampled for the Adult survey, go to Box P4.
PATH ID:

PN0001

Screen ID:

In the past 30 days, have you smoked a cigarette, a cigar, or a pipe?
1
2
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YES
NO

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-8
DON’T KNOW
-7
REFUSED
ASK: All respondents.
PATH ID:

PN0002

Screen ID:

In the past 30 days, have you used smokeless tobacco, such as chewing tobacco, snuff, snus or dip?
1
YES
2
NO
-8
DON’T KNOW
-7
REFUSED
ASK: All respondents.
PATH ID:

PN0003

Screen ID:

NOTE: SHOW CARD SC602. (CARD WILL HAVE GENERIC IMAGES OF ALL THESE PRODUCTS)
In the past 30 days, have you used any of the following: electronic or e-cigarettes (like Blu, Smoking
Everywhere, NJOY, Gamucci, or some other brand), a hookah or waterpipe, or a tobacco product that
dissolves in the mouth (such as Camel Orbs, Sticks or Strips)?
1
YES
2
NO
-8
DON’T KNOW
-7
REFUSED
ASK: All respondents.
PATH ID:

PT0029

Screen ID:

Do you think cigarettes or tobacco might be available to {CHILD’S FIRST NAME/AGE/SEX} at home?
1
YES
2
NO
-8
DON’T KNOW
-7
REFUSED
ASK: All respondents.

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CONTACT INFORMATION
BOX P4
ASK CONTACT INFORMATION 1 TIME FOR EACH PARENT RESPONDENT. IF PARENT IS AN SP
AND HAS ALREADY PROVIDED CONTACT INFORMATION AT THE END OF THE ADULT
INTERVIEW, DO NOT ASK CONTACT INFORMATION AGAIN.
PATH ID:

PL0001

Screen ID:

I’d like to take a brief moment and get some of your contact information for my records. I’ll use this
information to contact you about [INSERT ALL SAMPLED YOUTH AND SHADOW SAMPLED
CHILDREN’S NAMES]’s participation in the study.
I would like to re-confirm your name and street address.
[PROBE FOR APT AS NECESSARY. VERIFY ALL SPELLING.]
NAME: ______________________________________________________________
FIRST
MI
LAST
___________________________________________________________________
STREET
APT #
___________________________________________________________________
CITY
STATE
ZIP
PROGRAMMER NOTE: PRE-POPULATE NAME FIELDS (FIRST, MI, LAST) BASED ON INFO
OBTAINED IN THE SCREENER
PATH ID:

PL0002

Screen ID:

Do you receive mail at the address you just gave me?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

GO TO PL0004

ASK: All respondents.
PATH ID:

PL0003

Screen ID:

Can I please have your mailing address? [VERIFY ALL SPELLING.]
_________________________________________________________________
MAILING ADDRESS
__________________________________________________________________
CITY
STATE
ZIP
PROGRAMMER NOTE: PRE-POPULATE NAME FIELDS (FIRST, MI, LAST) BASED ON INFO
OBTAINED IN THE SCREENER

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PATH ID:

PL0004

Screen ID:

I’d like to get up to two telephone numbers to reach you in the future. Can I please have your telephone
number with area code?
__________
______________________________
AREA CODE
PHONE NUMBER
-8

DON’T KNOW

GO TO PL0006

-7

REFUSED

GO TO PL0006

ASK: All respondents.
PATH ID:

PL0005

Screen ID:

Is this your home phone, cell phone or work number?
1
2
3
4
-8
-7

HOME
CELL
WORK
OTHER
DON’T KNOW
REFUSED

ASK: All respondents.
PATH ID:

PL0006

Screen ID:

Can I please have a second telephone number with area code?
__________
______________________________
AREA CODE
PHONE NUMBER
-8

DON’T KNOW

GO TO PL0008

-7

REFUSED

GO TO PL0008

ASK: All respondents.
PATH ID:

PL0007

Screen ID:

Is this your home phone, cell phone or work number?
1
2
3
4
-8
-7

HOME
CELL
WORK
OTHER
DON’T KNOW
REFUSED

ASK: All respondents.

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PATH ID:

PL0008

Screen ID:

Do you have any other phone numbers you wish to provide?
__________
______________________________
AREA CODE
PHONE NUMBER
-8

DON’T KNOW

GO TO PL0010

-7

REFUSED

GO TO PL0010

ASK: All respondents.
PATH ID:

PL0009

Screen ID:

What type of phone number is this?
1
2
3
4
-8
-7

HOME
CELL
WORK
OTHER
DON’T KNOW
REFUSED

ASK: All respondents.
PATH ID:

PL0010

Screen ID:

What is the best number to use to contact you?
1
2
3
4
-8
-7

HOME
CELL
WORK
OTHER
DON’T KNOW
REFUSED

ASK: All respondents.
PATH ID:

PL0011

Screen ID:

What is the best time of day to reach you? Is it…
1
2
3
-8
-7

Morning
Afternoon
Anytime
DON’T KNOW
REFUSED

ASK: All respondents.

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PATH ID:

PL0012

Screen ID:

Can you please give me your e-mail address? [LIST UP TO 2 E-MAIL ADDRESSES. VERIFY ALL
SPELLING AND PUNCTUATION.]
_____________________________@________________
E-MAIL ADDRESS
_____________________________@________________
E-MAIL ADDRESS
ASK: All respondents.
PATH ID:

PL0013

Screen ID:

Do you have a Facebook® account?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

GO TO PL00015
GO TO PL00015
GO TO PL00015

ASK: All respondents.
PATH ID:

PL0014

Screen ID:

Can I please have your Facebook® name? We would only use this to contact you about the study. We
would not use it for any other reason. [VERIFY ALL SPELLING, PUNCTUATION AND SPACING.]
__________________________________________________
FACEBOOK® NAME
ASK: All respondents
PATH ID:

PL0015

Screen ID:

Do you have a Twitter® account?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

GO TO PL0017
GO TO PL0017
GO TO PL0017

ASK: All respondents.
PATH ID:

PL0016

Screen ID:

Can I please have your Twitter® handle? We would only use this to contact you about the study. We
would not use it for any other reason. [VERIFY ALL SPELLING, PUNCTUATION AND SPACING.]
__________________________________________________
TWITTER® HANDLE
ASK: All respondents.

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PATH ID:

PL0017

Screen ID:

Of all the contact information you just provided, what is the best way to reach you?
1
2
3
4
-8
-7

Is it your…

Home Phone
Cell Phone
Work Phone
E-mail
DON’T KNOW
REFUSED

ASK: All respondents.
PATH ID:

PL0018

Screen ID:

Do you anticipate moving or relocating either permanently or temporarily in the next 6 to 12 months?
1
2
-8
-7

YES
NO
DON’T KNOW
REFUSED

GO TO PL0020
GO TO PL0020
GO TO PL0020

ASK: All respondents.
PATH ID:

PL0019

Screen ID:

Can you provide any additional information on your relocation plans? For example, your new street
address or the city or state to which you plan to move? [PROBE FOR AND RECORD ANY KNOWN
INFORMATION.]
__________________________________________________________________
ASK: All respondents.
PATH ID:

PL0020

Screen ID:

In case we cannot reach you, can you please give me the contact information of two relatives, friends or
neighbors who will always know how to get in touch with you? We would prefer to have information on
someone who does not live with you. Who is the first person? [VERIFY ALL SPELLING.]
__________________________________________________________________
FIRST NAME
MI
LAST NAME
ASK: All respondents.

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PATH ID:

PL0021

Screen ID:

How is [FIRST NAME IN PL0020] related to you?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
91
92
-8
-7

HUSBAND/WIFE
FATHER/MOTHER
FATHER-IN-LAW/MOTHER-IN-LAW
GRANDPARENT
SON/DAUGHTER
SON-IN-LAW/DAUGHTER-IN-LAW
GRANDCHILD
BROTHER/SISTER
BROTHER-IN-LAW/SISTER-IN-LAW
AUNT/UNCLE/COUSIN
NIECE/NEPHEW
ROOMMATE
FRIEND
NEIGHBOR
OTHER RELATIVE (SPECIFY) ________________
OTHER NON-RELATIVE (SPECIFY) ____________
DON’T KNOW
REFUSED

ASK: All respondents.
PATH ID:

PL0022

Screen ID:

What is [FIRST NAME IN PL0020]’s address and telephone number? [VERIFY ALL SPELLING.]
_________________________________________________________________
MAILING ADDRESS
__________________________________________________________________
CITY
STATE
ZIP
_________
______________________________
AREA CODE
PHONE NUMBER
ASK: All respondents.
PATH ID:

PL0023

Screen ID:

What type of phone number is this?
1
2
3
4
-8
-7

HOME
CELL
WORK
OTHER
DON’T KNOW
REFUSED

ASK: All respondents who provided a telephone number in PL0022.
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PATH ID:

PL0024

Screen ID:

Can you please tell me [FIRST NAME IN PL0020]’s e-mail address? [VERIFY ALL SPELLING AND
PUNCTUATION.]
_____________________________@________________
E-MAIL ADDRESS
ASK: All respondents.
PATH ID:

PL0025

Screen ID:

What is the name of the second friend or relative? Again, we would prefer someone who does not live
with you.
__________________________________________________________________
FIRST NAME
MI
LAST NAME
ASK: All respondents.
PATH ID:

PL0026

Screen ID:

How is [FIRST NAME IN PL0025] related to you?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
91
92
-8
-7

HUSBAND/WIFE
FATHER/MOTHER
FATHER-IN-LAW/MOTHER-IN-LAW
GRANDPARENT
SON/DAUGHTER
SON-IN-LAW/DAUGHTER-IN-LAW
GRANDCHILD
BROTHER/SISTER
BROTHER-IN-LAW/SISTER-IN-LAW
AUNT/UNCLE/COUSIN
NIECE/NEPHEW
ROOMMATE
FRIEND
NEIGHBOR
OTHER RELATIVE (SPECIFY) ________________
OTHER NON-RELATIVE (SPECIFY) ____________
DON’T KNOW
REFUSED

ASK: All respondents.

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PATH ID:

PL0027

Screen ID:

What is [FIRST NAME IN PL0025]’s address and telephone number? [VERIFY ALL SPELLING.]
_________________________________________________________________
MAILING ADDRESS
__________________________________________________________________
CITY
STATE
ZIP
_________
______________________________
AREA CODE
PHONE NUMBER
ASK: All respondents.
PATH ID:

PL0028

Screen ID:

What type of phone number is this?
1
2
3
4
-8
-7

HOME
CELL
WORK
OTHER
DON’T KNOW
REFUSED

ASK: All respondents who provided a telephone number in PL0027.
PATH ID:

PL0029

Screen ID:

Can you please tell me [FIRST NAME IN PL0025]’s e-mail address? [VERIFY ALL SPELLING AND
PUNCTUATION.]
_____________________________@________________
E-MAIL ADDRESS
ASK: All respondents.

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