LGBT Campaign: Focus Group Study of Brand and Creative Concepts Designed to Prevent LGBT Young Adult Tobacco Use

OMB# 0910-0674

Exp. 03/31/2016

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1) When are you available to participate in a focus group? (Circle all that apply)
a. Saturday 11 AM – 12:30 PM	d. Sunday 11 AM – 12:30 PM
b. Saturday 1:30 PM – 3:00 PM	e. Sunday 1:30 PM – 3:00 PM
c. Saturday 4:00 PM – 5:30 PM	f. Sunday 4:00 PM – 5:30 PM

2) Do you consider yourself to be … (Circle one response)
a. Straight	d. Something else
b. Lesbian or gay	e. Don’t know
c. Bisexual

3) Some people describe themselves as transgender when they experience a different gender identity from their sex at birth. For example, a person born into a male body, but who feels female or lives as a woman would be transgender. Do you consider yourself to be transgender? (Circle one response)
a. Yes, Transgender, male-to-female	d. No
b. Yes, Transgender, female-to-male	e. Not sure
c. Yes, Transgender, gender nonconforming

4) On how many days of the PAST 30 DAYS did you smoke cigarettes? (Circle one response)

a. Number of days: __________________ (Fill in the blank)

b. None

c. Don’t know.

5) What is the highest grade or year of school you completed?
a. Never attended school or only attended kindergarten	d. Grade 12 or GED (High school graduate)
b. Grades 1 through 8 (Elementary)	e. College 1year to 3 years (Some college or technical school)
c. Grades 9 through 11 (Some high school)	f. College 4 years or more (College graduate)

7) What race or races do you consider yourself to be? (Circle all that apply)
a. American Indian or Alaska Native	e. Native Hawaiian or Other Pacific Islander
b. Asian	e. White
c. Black or African American	f. Other

6) Are you Hispanic or Latino? (Circle one response)

a. Yes

b. No

First Name:

Phone:

Circle One: CELL HOME

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Date: ____________________________________

Local Resident: Y N

Age: ____________________________________

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