Screening Questionnaire - screenshots

SCREEN QUESTIONNAIRE SCREENSHOTS
Form Approved
OMB No. 0920-0923
Exp. Date XX/XX/20XX
Evaluation of the National Tobacco Prevention and Control Public Education Screening
Questionnaire
Public reporting burden of this collection of information is estimated to average 5 minutes per
response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of
information. 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. Send comments
regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton
Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0923).

PREFER_LANG.

¿Prefiere contestar la encuesta en español o en inglés?
Do you prefer to do surveys in Spanish or English?
Español ................................................................... 1
English..................................................................... 2

KP_S1.

Welcome to the CDC Health Survey 2014! Your opinion counts!
Please try to answer all questions to the best of your ability. Your answers will be
kept private. We have a few qualifying questions about you and other members of
your household. If you are selected and complete our one-time 30-minute
interview, you'll receive 15,000 bonus points credited to your KnowledgePanel
account as our way of saying “thank you.”

ABS_S1.

Welcome to the CDC Health Survey 2014! Your opinion counts!
Please try to answer all questions to the best of your ability. Your answers will be
kept private. We have a few qualifying questions about you and other members of
your household. If you are selected and complete our one-time 30-minute
interview, you'll be sent $20 as our way of saying “thank you.”

First, are you currently 18 years old or older?
1. Yes
2. No

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ABS_S1a.

We will need to have this survey completed by someone who is 18 years old or
older from your household, can you have a person who is 18 or older from your
household complete this survey?
1. Yes
2. No
Our first few questions are primarily for classification purposes and they enable us
to select the questions to ask you later in the survey. They will also help us
properly analyze responses to this survey.

ABS_S3a.

How old are you (in years)?
_________ years old

ABS_S3b.

Are you…?
1. Male
2. Female

ABS_NQRACE1.

This is about Hispanic ethnicity. Are you of Spanish, Hispanic, or Latino
descent?
1.
2.
3.
4.
5.
6.
7.
8.

ABS_NQRACE2.

No, I am not
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, Central American
Yes, South American
Yes, Caribbean
Yes, Other Spanish/Hispanic/Latino

Please choose one or more races that you consider yourself to be.
1.
2.
3.
4.
5.

White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander

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ALL_G1619.

Would you say that you can…?
Very well

Pretty well

Just a little

Not at all

Carry on a conversation in Spanish,
both understanding and speaking
Read a newspaper or book in
Spanish
Carry on a conversation in English,
both understanding and speaking
Read a newspaper or book in
English

ABS_G20.

Do you or anyone in this household connect to the Internet from home?
1. Yes
2. No

ALL_G20a.

What type of Internet connection do you most often use at home to connect
to the Internet? Is it…?
1. Dial-up connection through the telephone
2. Wired with a high speed connection (cable, fiber optic, satellite, DSL,
etc.)
3. Wireless connection with a desktop computer, laptop, or tablet
4. Wireless connection with a cell phone or smart phone
5. Not at all sure
6. I personally cannot access the Internet at home

ALL_G20b.

What type of Internet connection are you currently using to take this survey?
1. Dial-up connection through the telephone
2. Wired with a high speed connection (cable, fiber optic, satellite, DSL,
etc.)
3. Wireless connection with a desktop computer, laptop, or tablet
4. Wireless connection with a cell phone or smart phone
5. Not at all sure

ALL_G12.

In which state do you live?
_________ Pull Down List of States + DC

ALL_G13.

What county do you live in?
_________ Pull Down List of Counties

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ALL_G14.

In what zip code do you live?
_______________

ABS_G14a.

You told us you live in zip code __________. Is this correct?
1. Yes
2. No

ALL_S3c.

Have you smoked at least 100 cigarettes in your entire lifetime?
1. Yes
2. No

ALL_S3d.

Do you now smoke every day, some days, or not at all?
1. Every day
2. Some days
3. Not at all

ALL_S2.

Including yourself, how many adults 18 or older are currently living in your
household?
1.
2.
3.
4.
5.
6.

1
2
3
4
5 or more
None, no adults live here

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ALL_S4.

Next, we’d like some brief information about each of the other adults in the
household. For each adult other than you, please answer the following
questions
ALL_4A. How old is
this person? (in years)

ALL_4B. Is this
person…?

ALL_4C. Smoked at
least 100 cigarettes?

Adult 1

O Male O Female

O Yes O No

Adult 2

O Male O Female

O Yes O No

Adult 3

O Male O Female

O Yes O No

Adult 4

O Male O Female

O Yes O No

Adult 5

O Male O Female

O Yes O No

ALL_S5.

For each person who smoked 100 or more cigarettes in his or her
lifetime, does he or she now smoke every day, some days, or not at all?
1. Every day
2. Some days
3. Not at all

ABS_END.

Thank you for your participation today. Your answers to this short survey
were very valuable to us, as of this time, all the longer surveys you could
participate in have been completed for us so you have not been selected
for our study.
Thanks again for your contribution to this important research.

ABS_S6.

Good news! You have been selected for our study, which takes about
30 minutes to complete for a $20 or higher reward, depending on your
qualification status.

INTRODUCTION. According to your previous responses, you qualify to participate in a survey
that will take about 30 minutes to complete. You will be asked various questions about your
experiences with tobacco and television ads about smoking as well as a few questions about
your background. The goal of this survey, which will include approximately 5,000 individuals
nationwide, is to provide more in-depth analysis of mass media efforts and smoker’s reactions
to television ads.
Your responses will be maintained in a secure manner and no personal identification
information will be passed on to the sponsors of this study. In addition, your name or other
personal information will never be associated with your responses. The data collected for this
research study will be combined with that of all participants before it is analyzed.

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If you choose to participate in this survey, you will be contacted to participate in a series of
follow-up surveys on a quarterly basis. The first follow-up survey will occur in approximately
[FILL # MONTHS PLANNED CAMPAIGN DURATION] months. The additional surveys will take
about the same amount of time to complete.
There are no physical risks involved in participating in this study; however, it is possible that you
could find some of the questions to be sensitive. If you find a question during the survey to be
too personal, you may choose not to answer the question. Your participation is strictly voluntary
and you may terminate your participation at any time. The benefit of participating in this study is
to assist the sponsor in determining a nationwide estimate of awareness of an important media
campaign. If you are qualified, you will be awarded 15,000 bonus points credited to your
KnowledgePanel account for completing the survey.
This survey is being conducted on behalf of the Centers for Disease Control and Prevention
(www.cdc.gov) and RTI International (www.rti.org), a non-profit research organization that
conducts studies on many types of health and social issues. If you have any questions about
this study, you can contact KnowledgePanel Panel Relations at 1-800-782-6899 and you will be
directed to the appropriate researchers.] If you have any questions about your rights as a study
participant, you can contact RTI’s Human Research Protections Office by email at [email protected],
or by phone at 1-866-214-2043 (a toll-free number). Please print or save a copy of this
document for your records.
ALL_CONSENT. I have read and understand the information provided above and the study
purpose and procedures are clear to me.
Yes, I agree to participate in this study. .................. 1
No, I do not wish to participate in this study. ........... 2

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