Community Health Wave 4 Screener

Form Approved
OMB No. 0920-0572
Expiration Date: 2/28/2015

Attachment 5a: Online Screener: Waves 1 - 4
(FHI 360, The Emery Group, & SmithGeiger on behalf of the Centers for Disease Control and Prevention,
Division of Community Health)
April 4, 2013
Introduction
SHOW: About this screener: Thank you for your interest in participating in this survey about health
information. Your participation in this survey is completely voluntary. The screener will take approximately
3 minutes to complete. If you qualify to participate, the online survey will take approximately 22 minutes of
your time. In this online survey you are going to be shown sample advertisements and asked to share your
honest opinions about them.
Your responses will be entered into a database and will only be seen by researchers associated with this
online survey. Your answers will be kept secure to the extent permitted by law. There will be no risk to you.
You may stop at any time. You will receive your gift, as it is explained in your online survey invitation, after
completing the online survey.
If you have any questions about this online survey or about your rights as an online survey participant,
please email them to [email protected].
By clicking 'Next,' I am agreeing to the above project description.
GENERAL SCREEN OUT MESSAGE UNLESS OTHERWISE NOTED: Thank you for your participation in
this online survey. Unfortunately, your responses indicate that you did not qualify for this particular online
survey, or that we have already reached our required quota of responses from participants similar to you.
We appreciate your enthusiasm for our online survey and hope you will join us on future online surveys!
Public Reporting Burden Statement
Public reporting burden of this collection of information is estimated to be approximately 3 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
(0920-0572).

1

Screening Criteria
S1.

What is your gender?
1
2

S2.

Male …………………………………………………………………………………..
Female…………….…………………………………………………………………..
[Recruit Approximately 50% Male and 50% Female]

Continue
Continue

In what year were you born?
1
2
3

S3.

Record year of birth: [4-DIGIT NUMERIC RESPONSE]…………………….
[Terminate if not age 25 to 64]
Don’t know/Not sure…………………………………….…………………….….
Refused…………………………………….………………………………..……..

Continue
Terminate
Terminate

What is the highest level of education you have completed?
1
2
3
4
5
6
7

Grade school…………………………………………………………………………..
Less than high school graduate/some high school……………………..………..
High school graduate or completed GED ………………………………………...
Some college or technical school ………………………………………………….
Received four-year college degree…………………………………………………
Some post graduate studies…………………………………………………………
Received advanced degree……………………………………………………….…

Continue
Continue
Continue
Continue
Continue
Continue
Continue

8

Other: _____________________ …………………………………………………
[Recruit a mix]

Continue

S4.

Please indicate your race or ethnic background. Are you….?
Ethnicity
1
2
1
2
3
4
5

SELECT ONE

Hispanic or Latino……………………………………………………….…………….
Continue
Not Hispanic or Latino……………………………………………………….………..
Continue
SELECT ONE OR MORE
Race:
White_............. ………………………………..……….……………………………..
Continue
Black or African American………………………………….………………………… Continue
American Indian or Alaska Native…………………………….……………………..
Continue
Native Hawaiian or Other Pacific Islander………………………………………..… Continue
Asian…………………………………….…………………………………………….… Continue
[Recruit by race/ethnicity according to current Census data projections]

2

S5.

In what state, city, and zip code do you currently live?
1
2
3

State: DROPDOWN LIST OF STATE CODES, ALPHABETIC CODED 1-50…. Continue
City: OPEN ENDED…………………………………………………………………… Continue
Zip code: NUMERIC FIELD WITH FIVE DIGIT ZIP ENTRY. …………………
Continue
[Recruit by population distribution according to current Census data projections]

S6. Do you, or does any member of your household or immediate family work:
1
2
3
4
5

For a market research company ………………………………………………….
For an advertising agency or public relations firm …………………………………
For the media (TV/radio/newspapers/magazines) ………………………………..
As a healthcare professional (doctor, nurse, pharmacist, dietician, etc.) ……..
None of the above………………………………………………………………….

Terminate
Terminate
Continue
Continue
Continue

S6_1. As a part of your job, are you physically active for a total of at least 30 minutes per work day?
(Add up all the time you spend in any kind of physical activity that increases your heart rate and
makes you breathe hard.)
1
2
S7.

Yes……………………………………………………………………………………...
No……………………………………………………………………………………...
[Recruit a mix]

Continue
Continue

Have you participated in a focus group, intercept interview, telephone survey, and/or online survey
in which you were asked your opinions regarding a product, a service, or advertising within the past
six months?
1
2

S8.

Yes……………………………………………………………………………………...
No……………………………………………………………………………………...

Terminate
Continue

About how often do you use the Internet?
1
2
3
4
5
6
7
8

Several times a day…………………………………………………………………
About once a day……………………………………………………………………
3-5 days a week…………………………………………………………………….
1-2 days a week…………………………………………………………………….
Every few weeks…………………………………………………………………….
Less often …………………………………………………………………………..
Never…………………………………………………………………………………
Don’t know/refused………………………………………………………………...
[Recruit a mix]

Continue
Continue
Continue
Continue
Continue
Continue
Terminate
Continue

3

S9.

About how much do you weigh without shoes?

_____ pounds ………………………………………………………………………………
8 Don‘t know / Not sure………………………………………………………………….
9 Refused………………………………………………………………………………….
S10.

Continue
Terminate
Terminate

About how tall are you without shoes?

_____ feet and _____ inches………………………………………………………………
8 Don‘t know / Not sure………………………………………………………………….
9 Refused………………………………………………………………………………….

Continue
Terminate
Terminate

S10_1. CODING, DO NOT DISPLAY – CALCULATE BMI BASED ON S10/S11
1
2

OVERWEIGHT OR OBESE
NOT OVERWEIGHT OR OBESE
[TARGET 838 RESPONDENTS (67%) WHOSE CALCULATED BMI PUTS THEM IN THE
OVERWEIGHT OR OBESE CATEGORIES.]

S11.

1

During the past 7 days, on how many days did you drink any regular soft drinks (non-diet) or other
sugary drinks – for example, regular pop or soda (non-diet), sugary sports drinks and energy
drinks, and fruit flavored drinks (not counting 100% fruit juice)?
Enter number: [Numeric Response] ……………………………………………...

Continue

[Recruit a mix: IF S11 = 0, SKIP TO S13. OTHERS CONTINUE TO S11_1]
S11_1. On average, on [IF S11=1, INSERT “that day” IF S11>1, INSERT “those ___[INSERT S11
RESPONSE]_ days”], how many regular soft drinks (non-diet) or other sugary drinks did you
drink?
1
S12.

1

Enter number: [Numeric Response: 1-100]……..……………………………..…
[Recruit a mix]

Continue

During the past 7 days, on how many days were you physically active for a total of at least 60
minutes per day? (Add up all the time you spent in any kind of physical activity that increased
your heart rate and made you breathe hard some of the time.)?
Enter number: [Numeric Response] ……………………………………………...
[Recruit a mix]

Continue

[Recruit a mix: IF S12 = 0, SKIP TO S13. OTHERS CONTINUE TO S11_1]
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S12_1. On average, on [IF S12=1, INSERT “that day” IF S12>1, INSERT “those ___[INSERT S12
RESPONSE]_ days”], for how many minutes were you physically active?
1
S13.
1

Enter number: [Numeric Response: 1-100]……..……………………………..…
[Recruit a mix]

Continue

During the past 7 days, on how many days did you make an effort to eat healthy meals and
snacks? NUMERIC RESPONSE 0-7.
Enter number: [Numeric Response] ……………………………………………...

Continue

[Recruit a mix: IF S13 = 0, SKIP TO INSTRUCTIONS BEFORE Q1. OTHERS CONTINUE TO
S13_1]
S13_1. On average, on [IF S13=1, INSERT “that day” IF S13>1, INSERT “those ___[INSERT S13
RESPONSE]_ days”], how many times did you eat healthy meals and snacks?
1

Enter number: [Numeric Response: 1-100]……..……………………………..…
[Recruit a mix]

Continue

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