Youth Reactions to Creative Advertising Concepts Designed to Reduce Tobacco Use among Multicultural Youth

SCREENER
OMB No: 0910-0674

Expiration Date: 03/31/2016

Paperwork Reduction Act Statement: The public reporting burden for this portion of the collection of
information has been estimated to average 7 minutes per response (the time estimated to understand the
instructions 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].

Screener
We are looking for about 20 students to be part of two
discussion groups after school. If you are selected and
agree to take part in the research activities, you will
receive a $25 VISA gift card that can be used anywhere.
Please answer the questions on the following page to see
if you qualify. We will let you know if you have been
selected to participate in your last period class today. The
discussion groups will take approximately 90 minutes on
[insert research day and date] after school.
Only the researchers will know what you write. We will not
share the answers you give with anyone outside of the
research study. Please rest assured that any information
you provide about your attitudes, beliefs and behaviors will
not
be
shared
with
your
school
or
your
parent(s)/guardian(s).
Please answer the questions based on what you really do,
and answer every question you are comfortable with.
There are no right or wrong answers to these questions.
Read the instructions carefully and let us know if you have
any questions.

Thank you very much for your help.

CONTINUE TO NEXT PAGE

First Name:
Last Name:
Last Classroom #/Teacher Today:
Last Classroom #/Teacher [insert research day]:
Phone:
(Circle One: CELL or HOME)

1) How old are you? (Circle one response)
a. 11 years old or younger

4) Do you think in the future you might try a
cigarette? (Circle one response)
a. Definitely Not

b. 12 years old
b. Probably Not

c. 13 years old

c. Probably Yes

d. 14 years old

d. Definitely Yes

e. 15 years old
f. 16 years old
g. 17 years old
h. 18 years old or older

5) If one of your best friends offered you a cigarette,
would you smoke it? (Circle one response)
a. Definitely Not
b. Probably Not

2) Have you used any tobacco products in
the last 30 days (i.e., cigarettes, cigarillos,
chewing tobacco, snus, e-cigarettes)?
(Circle one response)
a. Yes

c. Probably Yes
d. Definitely Yes

b. No

3) Do you think you will smoke a cigarette at any
time in the next year? (Circle one response)
a. Definitely Not
b. Probably Not
c. Probably Yes
d. Definitely Yes

CONTINUE TO NEXT PAGE

6) RANK THE 3 PEOPLE THAT

Rank #1:

WOULD BEST FIT IN YOUR
MAIN GROUP OF FRIENDS,
STARTING WITH THE BEST FIT.

Rank #2:

7) 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:

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8) RANK THE 3 PEOPLE THAT

Rank #1:

WOULD BEST FIT IN YOUR
MAIN GROUP OF FRIENDS,
STARTING WITH THE BEST FIT.

Rank #2:

9) 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:

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