LGBT Young Adult Tobacco Use Prevention Campaign: Copy Testing

OMB# 0910-0674 Exp. 3/31/2016

Screener
We are looking for people to be part of a survey about LGBT culture and
health. In order to be selected, participants must answer this short screener
survey to see if they qualify. You will find out if you have been selected at the
end of this screener survey. If you are selected, you will be asked to decide
if you want to participate in the full survey and get your $25 cash incentive.
There are no right or wrong answers to these questions.

Thank you very much for your help!

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 5 minutes per
response to complete the screener (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]

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1. Out of the last 30 days, on how many days
did you exercise for at least 30 minutes?
0. 0 days

3. 21 to 29 days

1. 1 to 10 days

4. All 30 days

2. In the past 30 days, on how many days did you
go to an LGBT party, night, club, bar or event?
0. 0 days
1. 1 to 3 days

2. 11 to 20 days

2. 4 to 6 days

3. When were you
born? (fill in the blanks)
Month (MM):
Day (DD):
Year (YYYY):

4. What is the 5-digit
zip code where you
CURRENTLY live?
___ ___ ___ ___ ___

6. What sex were you assigned at birth, on
your original birth certificate?
7. Prefer not to
1. Female
2. Male
answer
7. How often do you visit
websites for LGBT people,
such as Queerty,
Homorazzi, Autostraddle,
Towleroad, or After Ellen?
Never(1)

Often(5)

5. What is your current gender identity? (Circle
one response)
5. Genderqueer/ Gender
1. Male
non-conforming
6. Different identity (please
2. Female
state): _________________
3. Trans male/ Trans man

Number of days

(0-30) ______

88. Don’t
know

88. I don’t know the answer

7. Prefer not to answer

4. Trans female/ Trans
woman

8 On how many days of the
PAST 30 DAYS did you smoke
cigarettes?

10. Which of the following best represents how
you think of yourself?
5. Queer, pansexual,
1. Lesbian
trisexual, or omnisexual
6. Something else (please
2. Gay
specify):________________
3. Straight, that is, not
7. Prefer not to answer
lesbian or gay
4. Bisexual

3. 7 or more days
4. Don’t know how many
days

9. Have you ever received money or
gift cards from a company for sharing
your opinions about LGBT health in a
discussion group, interview, or survey?
1. Yes, WITHIN the
3. No
past 9 months
2. Yes, MORE THAN
4. I’m not sure
9 months ago

11. How many LGBT celebrities, athletes,
musicians, or artists do you follow on social
media, such as Connor Franta, Ruby Rose,
Laverne Cox, Ellen Page, RuPaul, Angel Haze,
Tom Daley, Janet Mock, Tegan & Sara, or Chaz
Bono?
0. 0

2. 3 - 4

1. 1 - 2

3. 5+

13. Are you Hispanic or Latino? (Choose one
response)

12. Do you or any member of your immediate
family or a close friend work for…? Select all
1. Yes
2. No
that apply.
1. A market research
4. The media (TV/radio/
14. What race or races do you consider yourself
company
newspapers/magazines)
to be? (Choose all that apply)
2. The tobacco industry
1. American Indian or
4. Native Hawaiian or
5. A healthcare
(manufacturers,
Alaska Native
Other Pacific Islander
professional (doctor, nurse,
distributors, or importers
5. White
pharmacist, dietician, etc.) 2. Asian
of tobacco products)
3. Black or African
3. An advertising agency
6. Other
American
6. None of these
or public relations firm

15. Your cell phone number:
(
)
—

16. Your e-mail address: