OMB No. 0920-0828
Exp. Date xx/xx/xxxx
TRAINING: Don’t Know/Not sure and Refused are not allowed.
If the person answering the phone refuses to answer these
questions or breaks off a call, or if the phone is not a cell
phone, code the Screener as a Refusal or other appropriate
disposition. This is true throughout the Screener.
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CPintro
/ASK ALL/
INTERVIEWER: PLEASE READ SLOWLY AND
DISTINCTLY
C1. 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. Please let me know
if you are currently driving a car or doing any activity that
requires your full attention, so I can call you back at a later
time.
[END
CALL IMMEDIATELY IF R IS DRIVING OR DOING AN ACTIVITY AND SET
APPOINTMENT.]
We're
gathering information on health and tobacco from selected cell
phone users across the United States. Your phone number has been
chosen randomly from a list of all cell phone numbers in the US.
It will take about 2 minutes to see if you qualify for the study.
Are you 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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Public
reporting burden of this collection of information is estimated to
average 1 minute 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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CPpHONEUSE
/ASK IF C1
CPINTRO EQ 1/
C2. Is
this phone number used for…
1. Personal use
2. Personal and business use,
or
3. Business use only
THANK AND END CALL
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CPname
/ASK IF C2
CPPHONEUSE EQ (1,2)
/LENGTH OF CPNAME = 20/
C3. To make sure that we
talk to you if we have to call you back, please give us a
first name to ask for. You can make up a name if you like.
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CPlandline
/ASK IF C2
CPPHONEUSE EQ (1,2)
C4. In your home, is a
cell phone the only way you can be reached by telephone?
1. YES GO TO C6
CPPRIVRES
2. NO
THANK AND END CALL
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CPprivres
/ASK IF C4
CPLANDLINE EQ 1/
C6. Do you live in a
house, an apartment, a condominium, or other type of private
residence?
interviewer:
if respondent is unsure about WHAT a “private residence”
IS, read:
Examples
of places where people live that are not
private residences are barracks, dormitories, and nursing homes.
Is the place where you live more like a house, an apartment or
condominium, or more like a barracks, a dormitory, or a nursing
home?
1. YES
2. NO
THANK AND END CALL
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CPconfidential
/ASK IF C6
CPprivres=1/
C7. You are eligible to
be interviewed.
You have been
selected to participate in this interview.
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.
Is respondent
continuing with the interview?
1. YES
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