Focus Group Study of Youth Reactions to Strategic and Creative Advertising Concepts Designed to Prevent Youth Tobacco Use among Multicultural Youth

OMB Control # 0910-0674
Expires: 3/31/2016

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Screener

We are looking for students to take part in a focus group after school.
If you are selected and agree to take part, you will receive a $25
gift card that can be used anywhere.
Please answer the questions on the following pages to see if you
qualify. We will let you know during your last period class if you were
selected. If so, you will be asked to stay after school for 90 minutes
on [DATE].

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Only the researchers will know how you answer. We will not
share the answers you give with anyone outside of the research
study. There are no right or wrong answers to these questions.

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Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average
of 5 minutes per response to complete the survey (the time estimated to read and complete). Send comments regarding this
burden estimate or any other aspects of this information collection, including suggestions for reducing burden, to
[email protected].

CONTINUE

First Name:

Last Name:

Last Classroom #/Teacher Today:

Phone:

Last Classroom #/Teacher on

1) How old are you?

:

(Circle One: CELL or HOME)

Last Classroom #/Teacher on

2) About how many cigarettes have you
smoked in your entire life? Your best guess
is fine.

a. 11 years old or younger
b. 12 years old

:

3) What is your sex?

a. Female

c. 13 years old

a. I have never smoked cigarettes, not even

one or two puffs

d. 14 years old

b. 1 or more puffs but never a whole cigarette

e. 15 years old

c. 1 to 99 cigarettes (less than 5 packs)

f. 16 years old

d. 100 or more cigarettes (5 or more packs)

b. Male

g. 17 years old
h. 18 years old or older

4) Do you think that you will
smoke a cigarette soon?

5) Do you think you will smoke a cigarette
in the next year?

a. Definitely yes

a. Definitely yes

b. Probably yes

b. Probably yes

c. Probably not

c. Probably not

d. Definitely not

d. Definitely not

e. Don’t know

e. Don’t know

f. Do not want to answer

f. Do not want to answer

7) Are you Hispanic or Latino?

6) If one of your best friends were
to offer you a cigarette, would you
smoke it?
a. Definitely yes
b. Probably yes
c. Probably not
d. Definitely not
e. Don’t know
f. Do not want to answer

8) What race or races do you consider yourself to be?
(You can choose one answer or more than one answer)

a. Yes

a. American Indian or Alaska Native

b. No

b. Asian
c. Black or African American
d. Native Hawaiian or Other Pacific Islander
e. White
g. Other

CONTINUE ON NEXT PAGE

9) RANK THE 3 PEOPLE THAT
WOULD BEST FIT IN YOUR
MAIN GROUP OF FRIENDS,
STARTING WITH THE BEST FIT.

10) RANK THE 3 PEOPLE THAT Rank #1:
WOULD LEAST FIT IN YOUR
Rank #2:
MAIN GROUP OF FRIENDS,
STARTING WITH THE WORST
FIT.

Rank #1:
Rank #2:

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Rank #3:

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Rank #3:

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11) RANK THE 3 PEOPLE THAT
WOULD BEST FIT IN YOUR
MAIN GROUP OF FRIENDS,
STARTING WITH THE BEST FIT.

Rank #1:

12) RANK THE 3 PEOPLE THAT
WOULD LEAST FIT IN YOUR
MAIN GROUP OF FRIENDS,
STARTING WITH THE WORST
FIT.

Rank #2:
Rank #3:

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Rank #1:
Rank #2:
Rank #3:

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