Form Approved
OMB
No. XXXX-xxxx
Exp.
Date xx/xx/xxxx
Dear Parent or Guardian,
Do you have a young person living in your home who is at least 12 years old, and not older than 17 years old?
If yes, please have this young person in your household between the ages of 12 and 17 complete this enclosed survey and mail it back using the enclosed postage-paid envelope.
If there is more than one person in this age group living in this household, please share this survey with the youth who has the next birthday coming up. This child with the next birthday is invited to complete the survey.
We may be interested in speaking with you again to discuss the study further. Please provide your name and the best phone number to reach you and mail it back to us along with your child’s completed survey.
Your Name _____________________ Phone Number _________________________
If there are no young people between the ages of 12 and 17 living in your household, please check the box below and return this packet to us using the enclosed postage-paid envelope.
I don’t have a youth between the ages of 12 and 17 living in my household.
The enclosed materials are for a study conducted by the U.S. Food and Drug Administration’s Center for Tobacco Products (CTP) called the Evaluation of the Fresh Empire Campaign on Tobacco.
For more information about the study, please contact [CONTACT NAME], at [CONTACT NUMBER] extension [CONTACT EXTENSION]. If you have a question about your rights as a study participant, you can call RTI’s Office of Research Protection toll-free at (866) 214-2043.
Your help is very important to this study’s success. Thank you for your cooperation.
Sincerely,
XXXXX
Evaluation of the Fresh Empire Campaign on Tobacco- Screener (EFECT-S)
Subjects for Questionnaire:
Section S: Study Screener
S1. How old are you?
1 Younger than 12 -- STOP. SKIP TO S8.
2 12 years old
3 13 years old
4 14 years old
5 15 years old
6 16 years old
7 17 years old
8 18 years old or older -- STOP. SKIP TO S8.
9 Prefer not to answer
S2. What is your gender?
1 Female
2 Male
3 Other (Please specify _______________)
9 Prefer not to answer
S8. Are you Hispanic, Latino/a, or Spanish origin? (One or more categories may be selected)
1 No, not of Hispanic, Latino, Latina, or Spanish origin
2 Yes, Mexican, Mexican American, Chicano or Chicana
3 Yes, Puerto Rican
4 Yes, Cuban
5 Yes, Another Hispanic, Latino/a or Spanish origin
9 Prefer not to answer
S9. What race or races do you consider yourself to be? (You can CHOOSE ONE ANSWER or MORE THAN ONE ANSWER or YOU MAY SKIP THIS QUESTION)
1 American Indian or Alaska Native
2 Asian
3 Black or African American
4 Native Hawaiian or Other Pacific Islander
5 White
9 Prefer not to answer
[DISPLAY I-BASE PHOTO ARRAY OF 36 FEMALES, then ask S3a and S3b]
S3a. Rank the three people that would BEST FIT in your main group of friends, starting with the best fit.
1 ____
2 ____
3 ____
S3b. Rank the three people that would LEAST FIT in your main group of friends, starting with the worst fit.
1 ____
2 ____
3 ____
[DISPLAY I-BASE PHOTO ARRAY OF 36 MALES, then ask S4a and S4b]
S4a. Rank the three people that would BEST FIT in your main group of friends, starting with the best fit.
1 ____
2 ____
3 ____
S4b. Rank the three people that would WORST FIT in your main group of friends, starting with the worst fit.
1 ____
2 ____
3 ____
S5. How much do you agree or disagree with the following statements?
|
|
1 Strongly Disagree |
2 Disagree |
3 Neither Agree or Disagree (Neutral) |
4 Agree |
5 Strongly Agree |
9 |
S5_1. |
I would like to explore strange places. |
1 |
2 |
3 |
4 |
5 |
9 |
S5_2. |
I like to do frightening things. |
1 |
2 |
3 |
4 |
5 |
9 |
S5_3. |
I like new and exciting experiences, even if I have to break the rules. |
1 |
2 |
3 |
4 |
5 |
9 |
S5_4. |
I prefer friends who are exciting and unpredictable. |
1 |
2 |
3 |
4 |
5 |
9 |
S10. What is your first name? ______________________________
Thank you for your time. Please place your completed survey in the postage paid envelope and return it to us.
Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 5 minutes per response to complete the mail screener (the time estimated to read, review, respond). 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 |
| File Modified | 0000-00-00 |
| File Created | 2021-01-25 |