OMB No. 0920-0828
Exp. Date xx/xx/xxxx
LINTRO1
/ASK ALL/
INTERVIEWER: PLEASE READ SLOWLY AND
DISTINCTLY
L1. Hello, my name is
[NAME FILL]. I'm calling for the CDC, the Centers for Disease
Control and Prevention. The CDC is a federal agency charged with
protecting and improving the public's health. We're gathering
information on health and tobacco from selected people across the
United States. Your phone number has been chosen randomly from a
list of all telephone numbers in the US.
Are you a member of this household and at
least 18 years old?
1. YES CONTINUE
2. NO, TOO BUSY, NOT A GOOD TIME, OR REQUESTS APPOINTMENT
CALLBACK OR APPOINTMENT
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LPHONEUSE
/ASK IF L1
LINTRO1 EQ 1/
L2. Is
this phone number used for…
1. Home use
2. Home and business use, or
3. Business use only
THANK AND END CALL
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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 Reports Clearance
Officer, 1600 Clifton Road, MS-74, Atlanta, GA 30333, ATTN: PRA
(0920-0828).
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Additional Information:
TRAINING: Don’t Know/Not sure and Refused
are not allowed. If the person answering the phone doesn’t
know the answers to the questions, attempt to get someone else to
the phone and re-read the introductory text. If no one is
available, schedule a callback. If the person answering the
phone refuses to answer these questions or breaks off a call, code
the Screener as a Refusal or other appropriate disposition. This
is true throughout the Screener.
Home use includes a phone which serves a house,
apartment, or condominium. If the phone serves a residence such as
barracks, dorm, or nursing home, code as business use only.
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lnoadult
/ASK
IF L2
LPHONEUSE EQ (1,2)/
[RANGE: 1-76,77,88,99]
[USE 76 FOR 76 OR MORE PEOPLE]
L3. The CDC uses the data
collected by this study to develop more effective public health
programs. Your household’s participation is voluntary and
important to the success of this study.
First, I need
to randomly select one adult who lives in your household to be
interviewed. Including yourself, how many adults age 18 and older
currently live in this household? Please do not include students
living away at school.
[IF NEEDED:
Include adults who think of this household as their primary place
of residence. Include adults who usually stay in the household but
are temporarily away on business, vacation, or in a hospital.]
_ _. Number of adults
If L3 Lnoadult=1 OR (L3
LNOADULT EQ 2 AND RESPONDENT ON PHONE IS SELECTED), Go to L4
LSELADULT1; ELSE IF L3
LNOADULT=2 AND RESPONDENT ON PHONE IS NOT SELECTED; ELSE IF L3
LNOADULT > 2 AND RESPONDENT ON PHONE IS NOT SELECTED, GO TO L6
LSELADULT3
|
lSELadult1
/ASK IF L3
LNOADULT=1 OR (LNOADULT=2 AND RESPONDENT ON PHONE IS SELECTED)/
L4. You have been
selected to participate in this interview. Please tell me just
your first name.
[IF FIRST NAME
REFUSED OR DON’T KNOW, ASK FOR INITIALS, AGE/SEX, RELATION
OR OTHER IDENTIFYING INFORMATION.]
[PROBE: We need
some way to ask for you if we need to call back.]
______________ first name or other identifier
IF SELECTED RESPONDENT PROVIDES IDENTIFIER,
CONTINUE WITH:
We're gathering
information on health and tobacco from selected people across the
United States. Your phone number has been chosen randomly from a
list of all telephone numbers in the U.S.
Your participation
in the study is voluntary. You don’t have to answer any
question you don’t want to, and you can end the interview at
any time. I won't ask for your full name, address, or other
personal information that can identify you.
The interview takes
about 15 to 25 minutes to complete, depending on your situation.
There are no known
risks to you for taking part in this interview. There are no
direct benefits to you for taking part in this interview, but your
answers are important and will help the CDC better understand
health issues and plan health programs. Your answers will be
maintained in a secure manner. Any information that might identify
you, such as your telephone number, will never be linked to your
answers and will not appear in any written reports or
publications.
If you have any
questions about this survey, I will provide a telephone number for
you to call to get more information.
This call may be
monitored for quality assurance.
GO TO L8
LSELRESMF
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LSELADULT2
/ASK IF LNOADULT=2 AND RESPONDENT ON PHONE IS
NOT SELECTED
L5. The other adult in
your household has been selected to participate in this interview.
Please tell me just the first name of the other adult in the
household.
[IF FIRST NAME
REFUSED OR DON’T KNOW, ASK FOR INITIALS, AGE/SEX, RELATION
OR OTHER IDENTIFYING INFORMATION.]
[PROBE: We need
some way to ask this person if we need to call back.]
______________ first name or other identifier
GO TO L7
LINTRO2
|
LSELADULT3
/ASK IF LNOADULT ≥ 3 AND RESPONDENT ON PHONE
IS NOT SELECTED
L6. Please tell me just
the first name of the adult in the household, other than yourself,
who will have the next birthday.
[IF NEEDED: We
are only interviewing one adult in each household and asking this
question helps the computer decide which person that should be.]
[IF FIRST NAME REFUSED OR DON’T KNOW, ASK FOR INITIALS,
AGE/SEX, RELATION OR OTHER IDENTIFYING INFORMATION.]
[PROBE: We
need some way to ask this person if we need to call back.]
______________ first name or other identifier
GO TO L7
LINTRO2
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lintro2
/ASK IF L5
LSELADULT2 IS NOT BLANK OR L6
LSELADULT3 IS NOT BLANK /
L7. May
I speak with [IDENTIFIER OF SELECTED RESPONDENT]?
[IF PERSON ON THE
PHONE IS NOT THE SELECTED RESPONDENT AND ASKS “Who’s
calling?”: SAY: Hello, my name is _________. I'm calling for
the CDC, the Centers for Disease Control and Prevention. We're
gathering information on health and tobacco from selected people
across the U.S.]
TRAINING: READ THE
TEXT ONLY IF THE PERSON WHO ANSWERS THE PHONE ASKS, “Who’s
calling?” WHEN THE SELECTED RESPONDENT COMES TO THE PHONE,
ENTER 1 AND READ THE INTRODUCTION THAT APPEARS ON THE NEXT SCREEN.
THIS IS IMPORTANT BECAUSE THE SELECTED RESPONDENT MAY NEED TO HEAR
OTHER INTRODUCTORY TEXT THAT SHOULD NOT BE READ TO JUST ANYONE
ANSWERING THE PHONE
IF SELECTED
RESPONDENT COMES TO THE PHONE: Hello, my name is ___________. I'm
calling for the CDC, the Centers for Disease Control and
Prevention. The CDC is a federal agency charged with protecting
and improving the public's health.
We're gathering
information on health and tobacco from selected people across the
United States. Your phone number has been chosen randomly from a
list of all telephone numbers in the U.S.
Your participation
in this study is voluntary. You don’t have to answer any
question you don’t want to, and you can end the interview at
any time. I won't ask for your full name, address, or other
personal information that can identify you.
The interview takes
about 15 to 25 minutes to complete, depending on your situation.
There are no known
risks to you for taking part in this interview. There are no
direct benefits to you for taking part in this interview, but your
answers are important and will help the CDC better understand
health issues and plan health programs. Your answers will be
maintained in a secure manner. Any information that might identify
you, such as your telephone number, will never be linked to your
answers and will not appear in any written reports or
publications.
If you have any
questions about this survey, I will provide a telephone number for
you to call to get more information.
This call may be
monitored for quality assurance.
1. CONTINUE
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lSELRESmf
/ASK IF L4
LSELADULT1 IS NOT BLANK OR L7
LINTRO2=1/
L8. IS THE SELECTED
RESPONDENT MALE OR FEMALE?
INTERVIEWER:
Ask only if necessary.
Are you male or
female?]
1. Male
2. Female
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