Data Collection Checklist

Form Approved

OMB No.: 0920-0621

Expiration Date: x/xx/xxxx

2015 NYTS DATA COLLECTION CHECKLIST

School Name: ____________________________________________ Date of Survey Administration: _____________________ Teacher: __________________________________ Grade(s): _____ Class: ______________________ Period: ______

Please Print Student Name or Identifier	Date Reminder Sent	Check if Permission Form was Returned “No”	Check if Permission Form was Returned “Yes”	If Student Did NOT Participate Record Eligibility Code	If Eligibility Code is: A, ISS, SR or NFR Student IS Eligible for Make-Up
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Public reporting burden for this collection of information is estimated to average 15 minutes per response, including 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, GA 30333, ATTN:PRA

Please Print Student Name or Identifier	Date Reminder Sent	Check if Permission Form was Returned “No”	Check if Permission Form was Returned “Yes”	If Student Did NOT Participate Record Eligibility Code	If Eligibility Code is: A, ISS, SR or NFR Student IS Eligible for Make-Up
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Public reporting burden for this collection of information is estimated to average 15 minutes per response, including 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, GA 30333, ATTN:PRA

MAKE-UP LIST
School Name: ________________________ State:_______­­­­­­­___________			Teacher Name(s):_______________________________ Class: __________________________Period:_______ Grades(s): _____
Dear Teacher: Students who were selected to participate but did NOT complete the survey and are eligible for a make-up are listed below. The list includes students who were coded as: A: Absent; ISS: In-School Suspension; SR: Student Refusal; and NFR: No Form Returned (for schools using active parental permission only). Students coded as NFR must have returned a signed parental permission form, with the “yes” box checked, to be surveyed as part of a make-up session. Students who initially refused to take the survey (SR) but voluntarily changed their mind and decide to participate, also may be surveyed. You are asked to administer a make-up with all students who meet the above criteria for a make-up survey administration. An adequate supply of survey booklets, student envelopes, and pencils is enclosed. When administering the survey, please follow the enclosed make-up survey administration guide closely. When you have completed the make-ups, please place each student’s sealed envelope containing his/her questionnaire in the white, business reply, pre-paid envelope marked MAKE-UPS along with this form. Please enter your name, school name and address on the envelope prior to mailing. For any student(s) not completing a make-up survey, please note the reason (if known) next to the student’s name below. Please return any unused survey booklets and envelopes. Please do NOT send back pencils. Important: If a student for all practical purposes has ceased to come to class or attend school and you cannot conduct a make-up, mark a capital “D” next to his/her name. Thank you again for your help. If you have any questions, please call us toll-free at 1-800-675-9727. PLEASE PRINT NAMES CLEARLY.
Students Needing Make-Ups	Code* (See list of codes below)	Students Needing Make-Ups		Code* (See list of codes below)

MAKE-UP SURVEY ADMINISTRATION GUIDE

NATIONAL YOUTH TOBACCO SURVEY

STEP 1 - VERIFY THAT ALL ASSEMBLED STUDENTS HAVE COMPLETED APPROPRIATE PERMISSION FORM PROCESS REQUIRED FOR THIS SCHOOL AND THAT NONPARTICIPATING STUDENTS (IF ANY) HAVE AN ALTERNATE ACTIVITY.

STEP 2 - AFTER STUDENTS ARE SEATED, DISTRIBUTE PENCILS AND STUDENT ENVELOPES. DO NOT DISTRIBUTE QUESTIONNAIRE BOOKLETS.

STEP 3 - INTRODUCE THE SURVEY TO THE CLASS.

I’d like to thank each of you for participating in the 2015 national Youth Tobacco Survey today. This survey is being conducted on behalf of the Centers for Disease Control and Prevention (also known as CDC). Participating in this survey is voluntary and your grade in this class will not be affected, whether or not you answer the questions. However, only a limited number of students like yourselves are participating in this survey in schools all over the Nation. The answers you give are very important so the results are accurate.

I would like to emphasize that this is not a test of you or our school. In order to help develop better education programs, educators and health officials must collect comprehensive data on the attitudes, knowledge, and behaviors of middle and high school students (grades 6‑12) with respect to tobacco, and on other influences that might make a youth susceptible to tobacco use in the future.

STEP 4 - DISTRIBUTE QUESTIONNAIRES. EMPHASIZE PRIVACY/ANONYMITY.

Throughout the entire survey process, we will maintain strict procedures to protect your privacy and allow for your anonymous participation. Please do not write your name on the questionnaire booklet or envelope. Your answers are private and we do not want to know your name. Results of this survey will never be reported by names, class, or school. When you finish the survey, place your survey booklet in the envelope provided, seal it, and leave it on your desk.

PAUSE HERE TO ANSWER ANY QUESTIONS...

STEP 5 - INSTRUCT THE CLASS IN FILLING OUT QUESTIONNAIRE.

Now I would like you to look at the questionnaire. Please take a moment to read the instructions on the front cover of the questionnaire.

(PAUSE)

Use the No. 2 pencil you have been given to fill out this survey. Do not use a pen or some other pencil. Notice that for each question on the survey, there is a corresponding set of ovals. For each question, choose the answer that best fits what you believe, or do, then fill in the corresponding oval. If you must change an answer, erase your old answer completely.

When you are finished, look over your booklet to make sure that you haven’t skipped any questions you wanted to answer. We have allowed 35 minutes for completing the survey. If you finish before that time, place your survey booklet in the envelope, seal it, and stay seated until I ask you to turn it in. It is important that you answer the questions based on what you really know, believe, and do. Don’t pick a response just because you think that’s what someone wants you to say. I am not allowed to answer any questions. Simply do the best that you can. Please begin.

NOTE TO TEACHERS:

(DO NOT READ ALOUD TO STUDENTS)

While students are taking the survey, place a check mark next to the names of those students on the Make-up List who are participating in the make-up session. If not all students listed on the Make-up list are completing a make-up, please note the reason next to their name on the list. Include this form when returning your make-ups.

Complete the return information in the upper left hand corner of the white, business reply make-up envelope including the number of completed booklets enclosed. Students may keep the pencils. Please do not return unused booklets.

STEP 6 - AT THE END OF CLASS PERIOD, COLLECT QUESTIONNAIRES.

The CDC would like to thank all of you for participating in this survey. The information you have provided will be used to develop better health education programs for students like yourselves all around the nation.

STEP 7- PLACE THE SEALED STUDENT ENVELOPES AND­ THE UPDATED MAKE-UP LIST IN THE LARGE WHITE BUSINESS REPLY ENVELOPE PROVIDED TO YOU BY THE DATA COLLECTOR. PLEASE SEND BACK ANY EXTRA UNUSED BOOKLETS AND ENVELOPES WITH THE COMPLETED SURVEYS. YOU MAY KEEP EXTRA PENCILS. DROP IN THE U.S. MAIL AS SOON AS POSSIBLE.

THANK YOU FOR PLAYING A VERY IMPORTANT ROLE IN THE SUCCESS OF THE NATIONAL YOUTH TOBACCO SURVEY.