OMB No.: Exp. Date:
RTI/FDA
Tobacco Focus Groups - Adults
Screening Questionnaire
Nicotine Knowledge
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 9 other people like you. The discussion group starts at [TIME] and will last no longer than 90 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 and your responses will be kept confidential. 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 YA group.
21–25 Recruit for YA group.
26–29 Recruit for Adult group.
30–34 Recruit for Adult group.
35–39 Recruit for Adult group.
40–45 Recruit for Adult group.
46–49 Recruit for Adult group.
50–59 Recruit for Adult group.
60–65 Recruit for Adult group.
Over 65 Recruit for Adult group.
2. Do you currently smoke cigarettes …? (Read list.)
Every day Continue, recruit for “Current”.
Some days Continue, recruit for “Intermittent”
Not at all Thank the respondent and terminate.
3. [Some days only.] On average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day? Would you say…? (Read list.)
Fewer than 10 Continue.
10 or more but less than 30 Continue.
30 or more Continue.
4. Do you typically smoke menthol cigarettes?
Yes Continue, eligible for Menthol group
No Continue, eligible for to “Current” group
5. Do you currently use any other tobacco product in addition to smoking cigarettes?
Yes Continue, assign to “Dual” group
If yes: Why types of tobacco products do you use?
Cigars, little cigars, or cigarillos
Pipes
Snus
Hookah
Chew tobacco, dip, or snuff
Dissolvable tobacco products
Electronic cigarettes (e-cigarettes)
Other: ___________________________
No Continue
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. On a scale of 1-5, how comfortable are you understanding and speaking English? 1 is very uncomfortable, 3 is somewhat comfortable, and 5 is very comfortable. ______________
[TERMINATE if 3 or lower]
Q11. On a scale of 1-5, how comfortable are you talking in a group of people your age? 1 is very uncomfortable, 3 is somewhat comfortable, and 5 is very comfortable. _______________
[TERMINATE if 3 or lower]
12. What is your sex? (Recruit equal numbers of males and females per group)
Male
Female
13. 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.
14. Are you Hispanic, Latino/a, or of Spanish origin? Choose all that apply.
No, not of Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, Another Hispanic, Latino/a, or Spanish origin
15. What is your race? Choose all that apply.
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Great! You qualify for our study. The discussion group will be held on [DATE] at [TIME] and will last no longer than 90 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.
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]. If you normally wear corrective lenses, contacts, or glasses to read please remember to have them with you during the focus group.
OMB No.: Exp. Date:
**NOTE** THIS PAGE MUST BE STORED SEPARATELY FROM THE SCREENER AND FOCUS GROUP DATA. PLEASE DESTROY UPON COMPLETION OF FOCUS GROUP.
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:
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 Denise Dickinson of RTI at 1-800-334-8571, ext. 25594 (toll free). 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 | FDA |
| File Modified | 2014-06-16 |
| File Created | 2014-06-16 |