Creative Concept Survey |
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Unique ID: |
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OMB Control # 0910-0674 |
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Expires 3/31/2016 |
Version ____________ |
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Ad #1__________ |
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Instructions: For each statement in the left column, circle the * that best represents your level of agreement or disagreement with that statement. |
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Completely Disagree |
Somewhat Disagree |
Neither Agree nor Disagree |
Somewhat Agree |
Completely Agree |
(a) This ad would convince people my age to LIVE TOBACCO-FREE. |
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(b) I would TALK ABOUT this ad with my friends. |
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(c) This ad would be RELEVANT TO MY FRIENDS AND ME. |
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Ad #2__________ |
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Instructions: For each statement in the left column, circle the * that best represents your level of agreement or disagreement with that statement. |
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Completely Disagree |
Somewhat Disagree |
Neither Agree nor Disagree |
Somewhat Agree |
Completely Agree |
(a) This ad would convince people my age to LIVE TOBACCO-FREE. |
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(b) I would TALK ABOUT this ad with my friends. |
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(c) This ad would be RELEVANT TO MY FRIENDS AND ME. |
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Ad #3__________ |
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Instructions: For each statement in the left column, circle the * that best represents your level of agreement or disagreement with that statement. |
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Completely Disagree |
Somewhat Disagree |
Neither Agree nor Disagree |
Somewhat Agree |
Completely Agree |
(a) This ad would convince people my age to LIVE TOBACCO-FREE. |
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(b) I would TALK ABOUT this ad with my friends. |
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(c) This ad would be RELEVANT TO MY FRIENDS AND ME. |
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Ad #4__________ |
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Instructions: For each statement in the left column, circle the * that best represents your level of agreement or disagreement with that statement. |
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Completely Disagree |
Somewhat Disagree |
Neither Agree nor Disagree |
Somewhat Agree |
Completely Agree |
(a) This ad would convince people my age to LIVE TOBACCO-FREE. |
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(b) I would TALK ABOUT this ad with my friends. |
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(c) This ad would be RELEVANT TO MY FRIENDS AND ME. |
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Ad #5__________ |
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Instructions: For each statement in the left column, circle the * that best represents your level of agreement or disagreement with that statement. |
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Completely Disagree |
Somewhat Disagree |
Neither Agree nor Disagree |
Somewhat Agree |
Completely Agree |
(a) This ad would convince people my age to LIVE TOBACCO-FREE. |
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(b) I would TALK ABOUT this ad with my friends. |
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(c) This ad would be RELEVANT TO MY FRIENDS AND ME. |
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Ad #6__________ |
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Instructions: For each statement in the left column, circle the * that best represents your level of agreement or disagreement with that statement. |
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Completely Disagree |
Somewhat Disagree |
Neither Agree nor Disagree |
Somewhat Agree |
Completely Agree |
(a) This ad would convince people my age to LIVE TOBACCO-FREE. |
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(b) I would TALK ABOUT this ad with my friends. |
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(c) This ad would be RELEVANT TO MY FRIENDS AND ME. |
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Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated |
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to average 45 minutes per response to complete (the time estimated to read, complete, and review responses in group discussion). |
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Send comments regarding this burden estimate or any other aspects of this information collection, including suggestions for reducing burden, to [email protected]. |
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