Qualitative Study on Consumer perceptions of Cigarettes Health Warning Images

OMB No. 0910-0796

Exp. 6/30/18

**NOTE** THIS PAGE MUST BE STORED SEPARATELY FROM THE SCREENER AND FOCUS GROUP DATA. PLEASE DESTROY UPON COMPLETION OF FOCUS GROUP.

NAME: ____________________________________________________________

ADDRESS: ________________________________________________________

CITY: _________________________________________________

ZIP CODE: _________________________________________________

E-MAIL_______________________________________________________

What is the best time to reach you? What is the best telephone number to reach you at that time?

BEST TIME TO BE REACHED: ________________________________________

BEST PHONE NUMBER: ________________________________________

Is there another time and number we can try if we miss you?

ALTERNATE TIME:

ALTERNATE PHONE NUMBER:

Thank you. That’s all the questions I have today. Please have your child arrive at least 15 minutes before the starting time. If you have any questions or find that your child is unable to attend, please call [facility’s phone number] as soon as possible. Thank you again for your time. We look forward to seeing your child at [TIME] on [DATE].

Read if necessary:

If you have any questions about the study, you may contact Denise Dickinson of RTI at 1-800-334-8571, ext. 25594 (toll free). If you have concerns about how participants are being treated in the study, you may contact RTI’s Office of Research Protection toll-free at 1-866-214-2043.