Form
Approved
OMB No. XXXX-xxxx
Exp. Date xx/xx/xxxx
Research and Evaluation Survey for the Public Education Campaign on Tobacco among LGBT (RESPECT)
Subjects for Screener:
Section AA: Interviewer selections and informed consent
Section A: Demographic items
Section B: Contact Information
Section AA Interviewer selections and informed consent
[AA1 and AA2 are for in-person recruits only. All others will skip to AA3.]
AA1. INTERVIEWER, SELECT CITY
AA2. INTERVIEWER, SELECT BAR
[GPS COORDINATES CAPTURED AT THIS SCREEN FOR AUTHENTICATION PURPOSES.]
AA3.
[INFORMED CONSENT TEXT WILL BE DISPLAYED HERE.]
Section A: Demographic Items
The first part of the survey asks you some general questions about yourself.
[AO is for social media participants only. In person interviews skip to A1.]
A0. How did you find out about this survey?
1 Facebook ad/Sponsored NewsFeed story
2 Twitter ad/Promoted Tweet
3 Someone sent it to me on Facebook
4 Someone sent it to me on Twitter
5 Someone sent it to me in another way
6 Another way (Specify)
9 Prefer not to answer
A1. What is the 5-digit zip code where you CURRENTLY live?
__ __ __ __ __ (5-digit, numeric responses only)
A2. What is your age?
___________ (Range: 15 to 80]
A3. What is your current gender identity?
1 Male
2 Female
3 Trans male/Trans man
4 Trans female/Trans woman
5 Genderqueer/Gender non-conforming
6 Different identity (please state): _______
9 Prefer not to answer
A4. What sex were you assigned at birth, on your original birth certificate?
1 Female
2 Male
9 Prefer not to answer
[If A3= 1 or 3 (male or trans male) display A5, ELSE display A6]
A5. Which of the following best represents how you think of yourself?
1 Gay
2 Straight, that is, not gay
3 Bisexual
4 Something else
5 I don’t know the answer
9 Prefer not to answer
[If A5= 4, go to A7, if A5= 5 go to A8, else go to A9]
A6. Which of the following best represents how you think of yourself?
1 Lesbian or gay
2 Straight, that is, not lesbian or gay
3 Bisexual
4 Something else
5 I don’t know the answer
9 Prefer not to answer
[If A6= 4, go to A7, if A6= 5 go to A8, else go to A9]
A7. What do you mean by something else?
1 You are not straight, but identify with another label such as queer, trisexual, omnisexual, or pansexual
2 You are transgender, transsexual, or gender variant
3 You have not figured out or are in the process of figuring out your sexuality
4 You do not think of yourself as having sexuality
5 You do not use labels to identify yourself
6 You mean something else
9 Prefer not to answer
[All Skip to A9]
A8. What do you mean by don’t know?
1 You don’t understand the words
2 You understand the words, but you have not figured out or are in the process of figuring out your sexuality
3 You mean something else
9 Prefer not to answer
A9. Have you attended a LGBT pride event in the past 12 months?
1 Yes
2 No
9 Prefer not to answer
A10. Have you ever tried cigarette smoking, even one or two puffs?
1 Yes
2 No
9 Prefer not to answer
A11. About how many cigarettes have you smoked in your entire life? Your best guess is fine.
1 1 or more puffs but never a whole cigarette
2 1 cigarette
3 2 to 5 cigarettes
4 6 to 15 cigarettes (about 1/2 a pack total)
5 16 to 25 cigarettes (about 1 pack total)
6 26 to 99 cigarettes (more than 1 pack, but less than 5 packs)
7 100 or more cigarettes (5 or more packs)
9 Prefer not to answer
A12. During the past 30 days, on how many days did you smoke cigarettes?
|_|_| days [RANGE: 0-30, 99]
A13. Have you ever received money or gift cards from a company for sharing your opinions about LGBT health in a discussion group, interview, or survey?
1 Yes, WITHIN the past 9 months
2 Yes, MORE THAN 9 months ago
3 No
4 I’m not sure
Eligibility Criteria
A1 validate zip code. If not valid, ineligible display C1
If [A1= valid
AND
A2= 18 to 24-years-old]
AND
[A3= 3 to 5
OR
A5= 1 or 3
OR
A6= 1 or 3
OR
A7= 1 or 2]
Eligible, display B1 (request contact information)
Else ineligible, display C1
Section B: Contact Information
Based on your answers to our questions, you may be eligible to complete our survey for a $20 digital gift card. Please provide your first name, email address and cell phone number so that we can send you a link to the web survey that you will complete on your own. You can choose whether you want to receive the link via email or text message. If you complete the survey within 48 hours you will receive an added $5 for a total of $25.
B1. First name.
1______________
Please provide your contact information so that we can send you the survey. We will try to send it with email or text, depending on which you prefer. Just in case, please provide both your email and cell phone number. We will only use this information to contact you about the survey.
B2. Email address (please provide an email address that you check regularly to ensure that you receive the survey link):
1______________
B2. Cell phone number ___-____-____
[If email address and/or cell phone number is already in our records go to C2, if new go to B3]
B3. The survey can be taken on a laptop, tablet or on the web on a smart phone, like an iPhone or a Droid.
How would you prefer to receive the survey link?
1 via email
2 via SMS text message on your smartphone
[Go to C3]
C1. Ineligible due to survey responses:
Thank you for your responses. We have no further questions at this time.
C2. Ineligible due to duplicate email address or cell phone number
Thank you for your responses. Our records indicate that we already have your email address or cell phone number on file. Thank you for completing the follow-up survey if you already have. If not, you will receive a reminder email or text message with the survey link to complete and receive your incentive.
C3. Eligible
Congratulations! You meet our criteria and are invited to complete our survey for a $20 digital gift card. Within the next 24 hours we will send you an email or text message with a link to the web survey that you will complete on your own.
[Intercept participants only]
If you complete the survey with 48 hours you will receive an added $5 for a total of $25.
OMB No: 0910-XXXX Expiration Date: XX/XX/XXXX
Paperwork Reduction Act Statement: The public reporting burden for this collection of information has been estimated to average 5 minutes per response. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to [email protected]
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Jamie Guillory |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |