OMB Control # 0910-0810 Exp.
Date: 11/30/18
SCREENER
Demographics
How old are you?
12 years old or younger [SCREEN OUT]
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old or older [SCREEN OUT]
Do you or any member of your immediate family or a close friend work for…?
A market research company
An advertising agency or public relations firm
The media (TV/radio/newspapers/magazines)
A healthcare professional (doctor, nurse, pharmacist, dietician)
The tobacco industry (manufacturers, distributors, or importers of tobacco products) [SCREEN OUT]
None of these
When was the last time you participated in a research study?
Within the past 6 months [SCREEN OUT]
More than 6 months ago
I have never participated in a research study
Are you…?
Female
Male
Are you Hispanic or Latino?
Yes
No
What race or races do you consider yourself to be? (mark one or more answers)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Cigarette Use
Have you ever tried cigarette smoking, even one or two puffs?
Yes
No
[If A7 = A, Ask A8. If A7 = B, Ask A9 – A11]
About how many cigarettes have you smoked in your entire life? Your best guess is fine.
1 or more puffs but never a whole cigarette
1 cigarette
2 to 5 cigarettes
6 to 15 cigarettes (about 1/2 a pack total)
16 to 25 cigarettes (about 1 pack total)
26 to 99 cigarettes (more than 1 pack, but less than 5 packs)
100 or more cigarettes (5 or more packs) [SCREEN OUT]
[If A8 = A – F, youth qualifies to participate in study. ]
Susceptibility
Thinking about the future…
Do you think you will try a cigarette soon?
Definitely yes
Probably yes
Probably not
Definitely not
Don’t know
Do you think you will smoke a cigarette at any time in the next year?
Definitely yes
Probably yes
Probably not
Definitely not
Don’t know
If one of your best friends were to offer you a cigarette, would you smoke it?
Definitely yes
Probably yes
Probably not
Definitely not
Don’t know
[If A9 – A11 All = D, SCREENOUT; otherwise youth qualifies to participate in study.]
Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 5 minutes per response to complete this survey (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].
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Alexander, Tesfa |
File Modified | 0000-00-00 |
File Created | 2021-01-26 |