Merchant Interview&Youth Focus Groups Reactions to Tobacco Product Flavor Bans

OMB Control Number: 0910-0674 Expiration Date: 03/31/2016

Institute for Health Research and Policy (MC 275)

5^th Floor, West Research Office Building

1747 West Roosevelt Road

Chicago, Illinois 60608

The City of Chicago Flavored Tobacco Product Ban near Schools

Focus Group Participant Check-In Survey

Name:_____________________________________________________________________________

Date of Birth: ______________________ Grade Level:_____________________

Gender: Female Male

Race/Ethnicity:

Are you of Hispanic, Latino, or Spanish origin? Yes No

If yes, please check one:

• Mexican, Mexican American, Chicano

• Puerto Rican

• Cuban

• Other Hispanic, Latino, or Spanish origin: ________________________________

What is your race?

• White

• Black or African American

• American Indian or Alaska Native

• Asian Indian

• Chinese

• Filipino

• Japanese

• Korean

• Vietnamese

• Other Asian race: ______________

• Native Hawaiian

• Guamanian or Chamorro

• Samoan

• Other Pacific Islander: ______________

• Other race: _______________

Home Address: ______________________________________________________________________

___________________________________________________________________________________

School:_____________________________________________________________________________

Tobacco use:

When was the last time you used any tobacco products?

• Never

• Within the last 5 years

• Within the last year

• Within the last month

• Within the last week

• Within the last day

When was the last time you used any flavored tobacco products such as menthol cigarettes, flavored cigarettes/cigarillos, flavored e-cigarettes, or flavored e-hookahs?

• Never

• Within the last 5 years

• Within the last year

• Within the last month

• Within the last week

• Within the last day

Do you know other adolescents (aged 14-18 years old) who use any flavored tobacco products?

• Yes

• No

Paperwork Reduction Act Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0910-0674 (expires 03/31/2016). The public reporting burden for this information collection has been estimated to average 10 minutes per response to complete the questions asked in this assent form (the time estimated to read and review). Send comments regarding this burden estimate or any other aspects of this information collection, including suggestions for reducing burden, to [email protected].

Youth Focus Group Questionnaire, Version 1, 1/21/2015

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