RTI/FDA
Tobacco Focus Groups
Screening Questionnaire
Hookah
Hello, this is _____________ from [FACILITY NAME], a local market research firm. May I please speak to_____________?
(Hello, this is _____________ from [FACILITY NAME], a local market research firm.) We are working with RTI International, a nonprofit research organization, and the Food and Drug Administration (FDA) on a research study about tobacco products, and would like to include your opinions. I want to assure you that we are not from a tobacco company or a company that sells quit-smoking aids.
We are holding a group discussion on [DATE] with approximately 7 other people like you. The discussion group starts at [TIME] and will last about 60 minutes. For study purposes, the group discussion will be audio recorded, and FDA project team members may observe the discussion.
In appreciation for your participation, you will be reimbursed for your time, effort, and travel expenses. Participation in the groups is completely voluntary. Would it be OK if I ask you a few questions now in order to see if you are eligible to be in one of the groups?
Yes – Continue.
No – Thank and end call.
What is your current age? _______
18–20 Recruit for 18-20 year old group.
21–25 Recruit for 21-25 year old group.
26–29 Thank the respondent and terminate
30–34 Thank the respondent and terminate
35–39 Thank the respondent and terminate
40–45 Thank the respondent and terminate
46–49 Thank the respondent and terminate
50–59 Thank the respondent and terminate
60–65 Thank the respondent and terminate
Over 65 Thank the respondent and terminate
2. Have you ever smoked a hookah or waterpipe?
Yes Continue.
No Terminate.
3. When was the last time you smoked a hookah?
Less than a month ago Continue.
1-3 months ago Continue.
4-6 months ago Continue.
7-9 months ago* Continue-mark as HOLD*.
10-12 months ago* Continue-mark as HOLD*.
More than a year ago Terminate.
*May need to hold those who used more >6 months, but <1 year ago for 21-25 year old group.
Have you ever used any other tobacco product besides hookah?
Yes Continue.
If yes: Why types of tobacco products have you used?
Cigarettes
Cigars, little cigars, or cigarillos
Pipes
Snus
Chew tobacco, dip, or snuff
Dissolvable tobacco products
Electronic cigarettes (e-cigarettes)
Other: ___________________________
No Go to Question 6 and assign to Hookah Only group
5. Have you used any of these tobacco products in the last 30 days?
Yes Continue and assign to Hookah and OTP group
If yes: Which products have you used in the past 30 days?
Cigarettes
Cigars, little cigars, or cigarillos
Pipes
Snus
Chew tobacco, dip, or snuff
Dissolvable tobacco products
Electronic cigarettes (e-cigarettes)
Other: ___________________________
No Continue and hold for Hookah Only group
6. In the past 5 years, have you or any member of your household worked for any of the following? (Read list. If yes to any, thank the respondent and terminate.)
A tobacco or cigarette company
A public health or community organization involved in communicating the dangers of smoking or the benefits of quitting
A marketing, advertising, or public relations agency or department
The Federal Government (Read list. If yes to any, thank the respondent and terminate.)
The U.S. Food and Drug Administration (FDA)
The National Institutes of Health (NIH)
The Centers for Disease Control and Prevention (CDC)
The Substance Abuse and Mental Health Services Administration (SAMHSA)
The Centers for Medicare & Medicaid Services (CMS)
7. Have you or any member of your household ever lobbied on behalf of the tobacco industry?
Yes Thank the respondent and terminate.
No Continue.
8. Have you or any member of your household personally represented or worked on behalf of a tobacco company in connection with a tobacco lawsuit?
Yes Thank the respondent and terminate.
No Continue.
9. Have you participated in any paid market research in the past 6 months?
Yes Thank the respondent and terminate.
No Continue.
10. For study purposes, if you participate, the discussion group will be recorded. The interviewer will not ask any sensitive questions. Are you okay with us recording your group discussion?
Yes Continue.
No Thank the respondent and terminate.
11. What is your sex?
Male
Female
12. What is the highest level of education that you have completed? (Read list. Recruit a mix to show per group. No more than two postgraduates per group.)
Less than high school diploma Continue.
High school graduate or GED Continue.
Some college or 2-year degree Continue.
College degree Continue.
Postgraduate degree Continue.
13. Are you of Hispanic or Latino origin?
Yes
14. What is your race? (Read list. Recruit a mix to show per group.)
White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaskan Native
[DON’T READ] Hispanic
[DON’T READ] Other
15. Finally, during the focus group discussion, you will be asked to review written materials and offer your opinions; therefore, I need to ask whether you have a medical or nonmedical condition that affects your ability to read and/or understand written materials in English?
Yes Thank the respondent and terminate.
No Continue.
Great! You qualify for our study. The discussion group will be held on [DATE] at [TIME] and will last about 60 minutes. For your time and opinions, you will receive $75 at the end of the session.
16. Would you like to participate in the group discussion at [TIME] on [DATE]?
Yes Continue.
No Thank the respondent and terminate.
Great! May I please have your mailing and/or e-mail address to send you a confirmation letter with directions? [Verify address and phone number.]
We are asking for your contact information only for the purpose of sending you a reminder letter and giving you a call to remind you of the discussion group. We will destroy all contact information at the conclusion of the groups.
NAME: ____________________________________________________________
ADDRESS: ________________________________________________________
CITY: _________________________________________________
ZIP CODE: _________________________________________________
E-MAIL_______________________________________________________
What is the best time to reach you? What is the best telephone number to reach you at that time?
BEST TIME TO BE REACHED: ________________________________________
BEST PHONE NUMBER: __________________
Is there another time and number we can try if we miss you?
ALTERNATE TIME:
ALTERNATE PHONE NUMBER:
**NOTE** THIS PAGE MUST BE STORED SEPARATELY FROM THE SCREENER AND FOCUS GROUP DATA. PLEASE DESTROY UPON COMPLETION OF FOCUS GROUP.
Thank you. That’s all the questions I have today. Please try to arrive at least 15 minutes before the starting time. If you have any questions or find that you are unable to attend, please call [facility’s phone number] as soon as possible. Thank you again for your time. We look forward to seeing you at [TIME] on [DATE].
Read if necessary:
If you have any questions about the study, you may contact Elizabeth Adams of RTI at (770) 407-4909. If you have concerns about how participants are being treated in the study, you may contact RTI’s Office of Research Protection toll-free at 1-866-214-2043.
| File Type | application/msword |
| File Title | Information Collection Request |
| Author | OPPDE/FSIS |
| Last Modified By | Johnson, Sarah |
| File Modified | 2013-06-10 |
| File Created | 2013-06-10 |