CTP - Adolescent Screener
A total of three, two hour focus groups - Recruiting 8 to seat 7-8; total of 24 recruits
Table 1
|
Louisville, KY |
Portland, OR |
New York, NY |
Age |
15-17 years old |
15-17 years old |
15-17 years old |
Gender |
Males |
Females |
Males |
Ethnicity |
Mix |
Mix |
Mix |
Education |
Mix |
Mix |
Mix |
Parent Introduction:
Hello Mr. /Ms. __________________________________, my name is __________________ and I would like to talk to you about a focus group study we plan to conduct for a health promotion agency. We are recruiting for an upcoming focus group in which participants will be asked to share their thoughts and feelings about information regarding health, health products, tobacco, advertising and marketing. We believe it is particularly important to talk with teens about this issue. Can we speak to _______________ [teen’s name] to see if they are able to participate in the study? If he/she is able to participate, we will need you to sign a consent form and have him/her bring it to the focus group.
YES NO
A
manufacturer or distributor of toys ……( ) (
)
and/or games
An advertising agency …….( ) ( )
A shoe manufacturer or retailer …….( ) ( )
A public relations firm …….( ) ( )
A candy company …….( ) ( )
A government health agency …….( ) ( )
A marketing or market research firm …….( ) ( )
An airline ……( ) ( )
A tobacco manufacturer, retailer or distributor.( ) ( )
A
tobacco advocacy or control group …….(
) ( )
of
tobacco products
SEX AGE GRADE
1. Male Female 1.________ 1.________
2. Male Female 2.________ 2.________
3. Male Female 3.________ 3.________
RECRUIT A MIX OF GIRLS & BOYS; MIX OF AGES 15-17 (only one per household)
____________________________________________________________________
( ) ...tend to be open, outgoing and talkative (CONTINUE)
or
( ) ...tend to be somewhat shy, quiet and reserved (THANK AND END INTERVIEW)
DATE:
CALL BACK TIME:
Yes (CONTINUE TO Q.6)
No (SKIP TO Q.7)
7A. Have you ever smoked a cigarette, chewing tobacco, dip, snuff etc.
Yes ______ (CONTINUE TO Q.7B)
No ______ (CONTINUE TO Q.8)
7B. Do you currently smoke a cigarette, chewing tobacco, dip, snuff etc., at least once a week
Yes ______ (CONTINUE TO Q.7C)
No ______ (CONTINUE TO Q.8)
7C. Thinking about a normal week during the school year, how many times would you say you have used tobacco in an average week? (DO NOT READ LIST. RECORD ONLY ONE RESPONSE.) ALL MUST BE CATEGORIZED AS HIGH RISK. Skip to Q.9
1 or 2 ( )
3-4
( )
5 or more ( )
8A Do you think you will use a tobacco product in the next year?
Definitely yes
Probably yes
Probably not
Definitely not
8B. Do you think that you will try a tobacco product soon?
Definitely yes
Probably yes
Probably not
Definitely not
8C. If one of your best friends were to offer you a tobacco product, would you use it?
Definitely yes
Probably yes
Probably not
Definitely not
NEITHER
STRONGLY AGREE
NOR STRONGLY
AGREE
AGREE DISAGREE DISAGREE DISAGREE
I make friends easily ( ) ( ) ( ) ( ) ( )
My friends often come to me for advice ( ) ( ) ( ) ( ) ( )
Among
my friends I am usually the first
to try new products, music or
clothes ( ) ( ) ( ) ( ) ( )
A lot of kids admire me ( ) ( ) ( ) ( ) ( )
10. Do any of your family members at home smoke or use tobacco?
( ) Yes (CONTINUE TO Q. 11)
( ) No (SKIP TO Q. 12)
11. What is their relation to you? What do they use?
Parent
Uncle/Aunt
Cousin
Other (since the adolescent may live with a grandparent, guardian, etc.___________________
Again, please know that all your answers will remain completely confidential to the fullest extent allowed by law for the next few questions, just try to answer as honestly as you can.
12. Are you of Hispanic/Latino Origin?
Yes [ ]
No [ ]
13. Which of the following best describes your ethnic background? (Record)
Caucasian q
African American q
Native Hawaiian/Pacific Islander q
American Indian/Alaskan Native……………………. q
Asian q
Other q
QUOTA: 50% CAUCASIAN, 25% AFRICAN AMERICAN, 25% OTHER ETHNICITY
( ) Yes (CONTINUE)
( ) No (THANK AND END INTERVIEW)
Invitation to youth:
From what you told me it looks like you are eligible to participate in the study. I would like to invite you to join about 8 other teens that also use tobacco products in a group discussion. The discussion will last no more than two hours, will be video- and audio-taped, and observed by the focus group staff. As I said earlier, your participation and everything you say during the discussion will remain confidential. You will receive $TBD for participating. Additionally, we will serve you snacks and beverages before the group discussion starts. Are you interested in participating in this focus group?
[YES] Continue
[NO] TERMINATE
Because you are under age 18, we will need a parent or guardian’s permission for you to be in the focus group. Will you be able to have a parent or a guardian sign a form giving you permission to attend?
[YES] Continue
[NO] TERMINATE
You will need to bring the consent form that I will provide to you. The form must have your parent or guardian’s signature when you come to the focus group. If you don’t have this consent form, you will not be able to participate.
I’m glad that you will be able to join us! The focus group will take place on [Day], [Date], at [6:00 or 8:00 p.m.] at [site location]. If you normally wear corrective lenses, contacts, or glasses to read please remember to have them with you during the focus group.
Will you be available to participate at this time?
[YES] Continue
[NO] TERMINATE
I will send you a confirmation letter and directions to the facility. In order to do so, could you please tell me your mailing address (or fax number, e-mail address) and a phone number where you can be reached:
Name:______________________________________
Address:__________________________________________________________
City:_______________________ State:_________ Zip:______________
Phone:_______________________
Email:_______________________
Date of focus group:__________________ Time:________________
We are only inviting a few people, so it is very important that you notify us as soon as possible if for some reason you are unable to attend. Please call [recruiter] at [telephone number] if this should happen. We look forward to seeing you on [date] at [time].
Great! That’s all the questions I have.
( ) Yes (CONTINUE)
( ) No (THANK AND END INTERVIEW)
File Type | application/msword |
File Title | HIGH RISK SCREENER |
Author | MS Office User |
Last Modified By | Gittleson, Daniel |
File Modified | 2012-03-14 |
File Created | 2012-03-13 |