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pdfCheck-In Survey
Please fill out this survey. Any information you share about your
attitudes, beliefs, and behaviors will not be shared with your school
or parents/guardians. No one outside the research team will know
what you write. There are no right or wrong answers to these
questions. Read the instructions for each question carefully and let
us know if you have any questions.
Thank you very much for your help.
CONTINUE
Unique ID: ______________
1) How old are you? (Select one response)
3) What is your sex? (Select one response)
a. 12 years old
b. 13 years old
a. Female
c. 14 years old
b. Male
d. 15 years old
4) Are you Hispanic or Latino? (Select one response)
e. 16 years old
f. 17 years old
a. Yes
5) What is your race? (Select one or more responses)
2) What grade are you currently in? (Select one
response)
a. 6th grade
e. 10th grade
b. 7th grade
f. 11th grade
c. 8th grade
g. 12th grade
d. 9th grade
h. Ungraded or other grade
b. No
a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Native Hawaiian or Other Pacific Islander
e. White
6) Have you ever tried cigarette smoking, even one or
two puffs? (Select one response)
a. Yes
b. No
For the following questions, please circle ONE answer in each row.
During the past 30 days, how many of your FRIENDS did this?
7)
Used Twitter
None
Some
About Half
Most
All
8)
Smoked cigarettes
None
Some
About Half
Most
All
9)
Used an App on their cell phone
None
Some
About Half
Most
All
10)
Logged into Facebook
None
Some
About Half
Most
All
11)
Used chewing tobacco, snuff, or dip, such
as Redman, Levi Garrett, Beechnut, Skoal,
Skoal Bandits, or Copenhagen
None
Some
About Half
Most
All
12)
Listened to music on Pandora or Spotify
None
Some
About Half
Most
All
13)
Smoked cigars, cigarillos, or little cigars like
Black and Milds or Swisher Sweets
None
Some
About Half
Most
All
14)
Visited a Tumblr page
None
Some
About Half
Most
All
15)
Posted a picture on Instagram
None
Some
About Half
Most
All
16)
Smoked menthol or mint cigarettes like
Kool, Newport, or Salem
None
Some
About Half
Most
All
CONTINUE ON NEXT PAGE
Unique ID: ______________
For the following questions, please circle ONE answer in each row.
During the past 30 days, on how many days did YOU do this?
17)
18)
19)
20)
21)
22)
23)
24)
25)
26)
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
Listened to music on Pandora or Spotify
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
Smoked cigars, cigarillos, or little cigars
like Black and Milds or Swisher Sweets
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
Visited a Tumbler page
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
0 days
1-2 days
3-5 days
6-9 days
10-19
days
20-29
days
All 30
days
Used Twitter
Smoked cigarettes
Used an App on your cell phone
Logged into Facebook
Used chewing tobacco, snuff, or dip, such
as Redman, Levi Garrett, Beechnut, Skoal,
Skoal Bandits, or Copenhagen
Posted a picture on Instagram
Smoked menthol or mint cigarettes like
Kool, Newport, or Salem
CONTINUE ON NEXT PAGE
27) RANK THE 3 PEOPLE THAT
Rank #1:
WOULD BEST FIT IN YOUR
MAIN GROUP OF FRIENDS,
STARTING WITH THE BEST FIT.
Rank #2:
28) RANK THE 3 PEOPLE THAT
WOULD LEAST FIT IN YOUR
MAIN GROUP OF FRIENDS,
STARTING WITH THE WORST
FIT.
Rank #3:
Rank #1:
Rank #2:
Rank #3:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
29) RANK THE 3 PEOPLE THAT
Rank #1:
WOULD BEST FIT IN YOUR
MAIN GROUP OF FRIENDS,
STARTING WITH THE BEST FIT.
Rank #2:
30) RANK THE 3 PEOPLE THAT
WOULD LEAST FIT IN YOUR
MAIN GROUP OF FRIENDS,
STARTING WITH THE WORST
FIT.
Rank #3:
Rank #1:
Rank #2:
Rank #3:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
21
32
Check-In Survey OMB Information
OMB No: 0910-0674
Expiration Date: 03/31/2016
Paperwork Reduction Act Statement: This document is part of the information collected under the
focus group portion of this information collection which includes understanding and answering the
Check-In Survey, Brand Test Stimuli, Hip Hop Brand Test Survey [Versions A and B], Preliminary
Creative Concept Testing Stimuli, Hip Hop Creative Concept Survey Spreadsheet, and the Moderator
Guide documents. The public reporting burden for this portion of the collection of information has been
estimated to average 90 minutes per response (the time estimated to understand the instructions,
participate in the focus group, and answer the questions). Send comments regarding this burden estimate
or any other aspects of this information collection, including suggestions for reducing burden, to
[email protected].
| File Type | application/pdf |
| File Title | Check-In Survey Part 1 |
| Author | Mayo M Djakaria |
| File Modified | 2013-12-20 |
| File Created | 2013-12-06 |