Online Questionnaire Recruitment Screener

Form Approved

OMB No. 0920-0910

Exp. Date 03/31/2018

National Tobacco Education Campaign

Online Questionnaire Recruitment Screener for

Rough Cut Testing of Television Advertisements

Public reporting burden of this collection of information is estimated to average 2 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0910).

{PREAMBLE}

On behalf of the Centers for Disease Control and Prevention (CDC), we're conducting a study about different health and smoking related advertising that you might see in the media, such as on TV or the internet. Your opinions are very important to us! The purpose of this survey is to gather your opinions on health and smoking-related advertising only; it is not to see products. We will not report your answers individually. We will report results from this survey for the group as a whole. Thank you for taking the time to help us! It will take about 2 minutes to determine your eligibility and about 13 minutes to complete the survey. Immediately upon completion of the survey, you will be provided with points equivalent to $0.50.

Your participation in this survey is voluntary. You may stop participating at any time.

{Demographic Information}

DAGE2. What is your current age, in years?

_ _ _ age in years

{Open-end}

999 Prefer not to answer {GENERAL SCREEN OUT MESSAGE}

{Terminate if <18 years old or >54 - go to GENERAL SCREEN OUT MESSAGE}

{Smoking Behavior}

{PREAMBLE}

The next questions are about traditional cigarettes, which are any form of tobacco wrapped in paper. Traditional cigarettes typically come in packs of 20, and some brand examples include Marlboro, Newport, Camel, Lucky Strike and Pall Mall.

{Base = All respondents}

TS1. Have you smoked at least 100 traditional cigarettes in your entire life?

1. Yes

2. No

3. Don’t know/not sure {GENERAL SCREEN OUT MESSAGE}

4. Prefer not to answer {GENERAL SCREEN OUT MESSAGE}
   
   

{Base = TS1 = 01}

TS2. Do you now smoke traditional cigarettes every day, some days, or not at all?

1. I smoke every day

2. I smoke on some days

3. I do not smoke at all

{Base = TS2 = 01, 02}

TS3. On how many of the past 30 days did you smoke traditional cigarettes?

Enter number: _______

777 Don’t know/Not Sure {GENERAL SCREEN OUT MESSAGE}

999 Prefer not to answer {GENERAL SCREEN OUT MESSAGE}

{If Respondent answers TS1 = 1 AND (TS2 = 1 or TS2 = 2) AND answers TS3 > 0, code as smoker; otherwise code as NONSMOKER, show GENERAL ELIGIBILITY MESSAGE}

Segments	Definition	Criteria
Smokers	Adult who has smoked > 100 cigarettes in their lifetime, smoked at least one cigarette in the past 30 days, currently smokes cigarettes every day or some days, and is between 18-54 years old.	IF TS1_1 AND (TS2_1 or TS2_2) AND TS3 > 0
Nonsmokers	Adult who did not currently smoke, had not smoked a traditional cigarette in the past 30 days, and is between 18-54 years old.	IF TS1_2 AND (TS2_3) AND TS3 = 0

{GENERAL SCREEN OUT MESSAGE}

Thank you for your participation in this study. Unfortunately, your responses indicate that you do not fit the specific criteria needed for this particular study, or that we have already reached our required quota of responses from participants similar to you. We appreciate your enthusiasm for our study and hope you will join us on future surveys!

{GENERAL ELIGIBILITY MESSAGE}

Thank you for your participation in this study. Your responses indicate that you qualify and fit the specific criteria needed for this particular study. Click “Next” to begin the survey.

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