Main study, parents (both acne and ADHD)

Adolescent Direct-to-Consumer Marketing

Combined Adolescent/Young Adult/Parent Questionnaire

COLOR GUIDE

YELLOW	PARENT ONLY TEXT
LIGHT GREY	ADOLESCENT AND YOUNG ADULT TEXT
TURQUOISE	ADOLESCENT ONLY TEXT
GREEN	PARENT AND YOUNG ADULT TEXT

PINK PARENT AND ADOLESCENT TEXT

SCREENER FOR ADOLESCENTS AND PARENT/ADOLESCENT DYADS (GIVEN TO PARENTS)

[Note: The following will be present at the bottom of the first screen:

This research is authorized by Section 1701(a)(4) of the Public Health Service Act (42 U.S.C. 300u(a)(4)). Confidentiality protected by 5 U.S.C. 552(a) and (b) and 21 CFR part 20.

OMB Control #_____ Expires _____]

1. Are you the parent or guardian of any children between the ages of 13-17?

Yes

No terminate

2. How many children in each of these age groups live with you at least half the time? Please only answer for children for which you are the parent or guardian.

13 years old 0 1 2 3 4

14 years old 0 1 2 3 4

15 years old 0 1 2 3 4

16 years old 0 1 2 3 4

17 years old 0 1 2 3 4

Programmer: If 0 for all age groups, terminate.

3. For your [AGE] year old child (programmer: IF >1 child in any age group, use “OLDEST [AGE] year old child” for this question and repeat for next oldest) please enter the child’s first name and your relationship to the child.

Child’s Name: _____________ (free response)

Child’s Sex: Male Female

Your relationship to this child: Programmer: use drop down menu: mother, father, stepmother, stepfather, grandmother, grandfather, aunt, uncle, guardian, other (specify)

4. Has a medical professional ever diagnosed [CHILD FIRST NAME] with any of the following conditions? (Select all that apply)

ADHD

Allergies

Asthma

Autism

Celiac Disease

Diabetes

Epilepsy

Gastro Esophageal Reflux Disease (GERD)

Lyme Disease

Tonsillitis

None of the above

Programmer: Repeat Q.4 for all children named in Q.3. If ADHD = yes, assign to ADHD condition and skip Q.5; else continue to Q.5. IF >1 child = yes, choose child based on least filled age group.

5. Which of the following does your child currently have or has your child had in the past? (Select all that apply)

Acne

Chicken Pox

Constipation

Influenza (flu)

Lice

Milk/dairy allergies

Skin irritation/rashes

Sleep issues

None of the above

Programmer: Repeat Q.5 for all children named in Q.3. If Acne = yes, assign to Acne condition; else terminate. IF >1 child = yes, choose child based on least filled age group.

SCREENER FOR YOUNG ADULTS

1. Which of the following best describes your age range:

Under 18 (terminate)

18 to 24 (terminate)

25 to 30

31 to 35 (terminate)

36 to 40 (terminate)

41 to 45 (terminate)

46 to 50 (terminate)

2. Has a medical professional ever diagnosed you with any of the following conditions? (Select all that apply)

ADHD

Allergies

Asthma

Autism

Celiac Disease

Diabetes

Epilepsy

Gastro Esophageal Reflux Disease (GERD)

Lyme Disease

Tonsillitis

None of the above

Programmer: If ADHD = yes, assign to ADHD condition and skip Q.3; else continue to Q.3.

3. Which of the following do you currently have or have you had in the past? (Select all that apply)

Acne

Chicken Pox

Constipation

Influenza (flu)

Lice

Milk/dairy allergies

Skin irritation/rashes

Sleep issues

None of the above

Programmer: If Acne = yes, assign to Acne condition; else terminate.

CONSENT/ASSENT TEXT

[CHILD FIRST NAME] is you are being invited to participate in a research study about prescription drugs. The purpose of the study is to learn more about how people find information and make decisions about prescription drugs.

If you agree to let [CHILD FIRST NAME] participate, [he/she] you will look at an ad for a prescription drug on the computer and complete a survey. The survey includes questions about risks and benefits of prescription drugs, use of medications, and personal characteristics. There are also some questions about communication between parents and teenagers, particularly about medications.

There is no direct benefit to your child you for participating. However, [CHILD FIRST NAME] you will help researchers learn how people make decisions about prescription drugs and the information they see in prescription drug advertisements.

There are no known risks to participating in this study. While the questions are not meant to be sensitive, there is always a chance that [CHILD FIRST NAME] you may feel uncomfortable with some of the questions. [CHILD FIRST NAME] does You do not have to answer any question that he or she doesn’t you don’t want to answer.

[CHILD FIRST NAME]’s Your personal information (name, address, phone number) will not be linked to any of his or her your responses. No participants will be identified in any report or publication of this project or its results.

[CHILD FIRST NAME]’s Your participation in this study is voluntary. [CHILD FIRST NAME] You may stop answering the survey questions at any time.

If you agree for [CHILD NAME] to participate in the survey, please let [him/her] know that it’s okay with you if [he/she] answers our questions and please allow [him/her] to complete the survey in private, where no one else can see [his/her] answers. Your child’s survey will appear on the next screen. If your child is not available right now, please close your browser and access the link again when your child is available.

NEXT (by clicking “next” I certify that I agree for my child to complete the survey in private.)

(by clicking “next” I certify that I agree to complete the survey in private.)

Programmer: For adolescents, repeat above screen using adolescent version when adolescent opens up the survey.

NTRODUCTION

[PROGRAMMER: Randomly assign participants to study conditions.]

Hcondition – assign based on screener

CONDITION=ADHD	ATTENALIX	N=999
CONDITION=ACNE	CLARIVAE	N=999

HassignATTENALIX [ADHD]–assign based on least filled

HIGH RISK	N=999
LOW RISK	N=999

HassignCLARIVAE [ACNE] –assign based on least filled

HIGH RISK	N=999
LOW RISK	N=999

INFONODE

Thank you again for taking time from your busy schedule to take part in this research. Remember: your answers will not be linked to your name.

This study involves information about a drug that is not yet available for sale. You will look at a website page and watch a short video, and then will be asked to answer the questions that follow.

Make sure you are comfortable and can read the screen from where you sit. The ad will include some audio, so please make sure the sound on your computer is active and the speaker volume is turned up.

The survey will take about 30 minutes to complete. We ask you to complete the survey in one sitting (without taking any breaks) in order to avoid distractions.

[PROGRAMMER: Display ad correspondent to the participant’s experimental condition [HASSIGN]. Record duration of time spent watching ad and also time spent on each screen answering questions. Video component of ad should run twice. Also, please disable the “Next” button while each video is playing to prevent participant from skipping ahead.]

[VIDEO VIEWING ABILITY CHECK]

Q1. Were you able to view and hear the ad?

SC

Yes [Continue]

No [Terminate; Link to screening responses and keep data]

[SECTION A: Recall and Comprehension]

INFONODE: The following questions will ask you what you remember from the [DRUG NAME] ad you just saw. Please type your answers in the space given.

A-1. What are the most important messages of this ad? Please use one box for each message. You do not need to use all the boxes. [Open-ended response]

OE CHA

VALIDATION: NONE

[Randomize order of A-2 and A-3.]

The advertisements you saw included messages about a prescription drug named [DRUG NAME].

A-2. Based on the ad you viewed, what are the benefits of [DRUG NAME]? Please name as many benefits as you can remember. Please use one box for each benefit. [Open-ended response]

Click here to enter another benefit.

[Programmer: If clicked, insert another open-ended box above prompt. Have an option to add boxes after each one.  The limit for OE boxes for each is 15.]

A-3. Based on the ad you viewed, what are the side effects from [DRUG NAME]? Please name as many side effects as you can remember. Please use one box for each side effect. [Open-ended response]

Click here to enter another side effect.

[Programmer: If clicked, insert another open-ended box above prompt. Have an option to add boxes after each one.  The limit for OE boxes for each is 15]

A-4. How much do you agree or disagree with the following statement:
People like me can understand the ad that I saw for [DRUG NAME].

SC

strongly disagree

disagree

somewhat disagree

neither agree nor disagree
somewhat agree
agree

strongly agree

[SECTION B: Risk/Benefit/Efficacy Perceptions]

INFONODE: The following questions ask about how you think [DRUG NAME] would affect your child you if your child you were taking it for his/her your [MEDICAL CONDITION]. To answer the questions, think about when your child’s your [MEDICAL CONDITION] was at its worst. Please select one answer for each question.

B-1. How long do you think it would take for you to see an improvement in your child’s your [MEDICAL CONDITION] after starting [DRUG NAME]?

SC

1-2 days

3-5 days

2-5 weeks

8-10 weeks

3-5 months

6-12 months

I don’t think [DRUG NAME] would improve my child’s [MEDICAL CONDITION]

B-2. Once you see an improvement in your child’s [MEDICAL CONDITION], how long do you think the improvement will last if your child continues you continue to take [DRUG NAME]?

SC

1-2 days

3-5 days

2-5 weeks

8-10 weeks

3-5 months

6-12 months

I don’t think [DRUG NAME] would improve my child’s [MEDICAL CONDITION]

The improvement will last as long as my child continues I continue to take [DRUG NAME]

B-3. If [DRUG NAME] did cause side effects, how serious do you think they would be?

SC

not at all serious

somewhat serious

very serious

B-4. How do you think any side effects of taking [DRUG NAME] compare to any benefits of taking [DRUG NAME]?

SC

side effects much greater than benefits

side effects greater than benefits

side effects somewhat greater than benefits

side effects and benefits are equal

benefits somewhat greater than side effects

benefits greater than side effects

benefits much greater than side effects

B-5. Do you think [DRUG NAME] would work better or worse than other [MEDICAL CONDITION] drugs?

SC

[DRUG NAME] would work a lot better

[DRUG NAME] would work better

[DRUG NAME] would work a little better

[DRUG NAME] would work just as well

[DRUG NAME] would work a little worse

[DRUG NAME] would work worse

[DRUG NAME] would work much worse

B-6. Do you think the side effects of [DRUG NAME] would be more serious or less serious than other [MEDICAL CONDITION] drugs?

SC

The side effects of [DRUG NAME] would be much more serious

The side effects of [DRUG NAME] would be more serious

The side effects of [DRUG NAME] would be a little more serious

The side effects of [DRUG NAME] would be neither more nor less serious

The side effects of [DRUG NAME] would be a little less serious

The side effects of [DRUG NAME] would be less serious

The side effects of [DRUG NAME] would be much less serious

[Show B-7 and B-8 on same screen for first benefit; then repeat for next benefit; randomize the order in which benefits are presented]

B-7. How likely is it that your child YOU will have [BENEFIT] from [DRUG NAME]?

SC

very unlikely

unlikely

somewhat unlikely

neither unlikely nor likely

somewhat likely

likely

very likely

[BENEFIT] is not a benefit of [DRUG NAME]

BENEFITS FOR ACNE CONDITION

1. less swelling caused by acne

2. fewer pimples caused by acne

BENEFITS FOR ADHD CONDITION:

1. decreased impulsivity

2. decreased hyperactivity

3. increased attention

B-8. When choosing whether or not to allow your child to take [DRUG NAME], how important is [BENEFIT]?

SC

very important

important

somewhat important

neither important nor unimportant

somewhat unimportant

unimportant

very unimportant

B-9. How likely is it that your child YOU will have the following side effects from [DRUG NAME]?

GRID SC PER ROW

[Ask question for each side effect on list below based on assigned condition [HASSIGN]; randomize order in which side effects are presented. Use grid.]

very unlikely

unlikely

somewhat unlikely

neither unlikely nor likely

somewhat likely

likely

very likely

[SIDE EFFECT] is not a side effect of [DRUG NAME]

FOR LOW SEVERITY PROFILE CONDITION:

• difficulty sleeping

• increased blood pressure

• rapid heartbeat

• Increased sensitivity to light

• fatigue

• nausea

• dizziness [common to high and low profile]

• dry mouth [bogus – not in ad]

• nervousness [bogus – not in ad]

FOR HIGH SEVERITY PROFILE CONDITION:

• an abrupt decrease in night vision

• liver failure

• suicidal thoughts or actions

• seizures/convulsions

• hair loss

• deafness

• dizziness [common to high and low profile]

• dry mouth [bogus – not in ad]

• nervousness [bogus – not in ad]

[Programmer: Use one screen per side effect from B-9 for questions B-10 to B-13 IN A LOOP based on assigned condition. Repeat with a new screen for the next side effect. For the low risk condition, the 3 side effects we will ask about are increased blood pressure, rapid heartbeat, dizziness; For the high risk condition, the side effects are: suicidal thoughts or actions, liver failure, dizziness]

INFONODE: For the following questions, please answer for [SIDE EFFECT].

B-10. My child’s chances of having [SIDE EFFECT] in the future as a result of taking [DRUG NAME] are:

SC

much below average

below average

a little below average

average for people my age

a little above average

above average

much above average

[SIDE EFFECT] is not a side effect of [DRUG NAME]

B-11. When choosing whether or not to allow your child to take [DRUG NAME], how important is the side effect: [SIDE EFFECT]?

SC

very important

important

somewhat important

neither important nor unimportant

somewhat unimportant

unimportant

very unimportant

[SIDE EFFECT] is not a side effect of [DRUG NAME]

B-12. How long do you think it will take for your child to have [SIDE EFFECT] after starting [DRUG NAME]?

SC

1-2 days

3-5 days

2-5 weeks

10-12 weeks

3-5 months

6-12 months

I don’t think my child I’ll will have [SIDE EFFECT]

[SIDE EFFECT] is not a side effect of [DRUG NAME]

B-13. Once your child stops you stop taking [DRUG NAME], how long do you think [SIDE EFFECT] will last?

SC

1-2 days

3-5 days

2-5 weeks

10-12 weeks

3-5 months

6-12 months

I don’t think my child will I’ll have [SIDE EFFECT]

[SIDE EFFECT] is not a side effect of [DRUG NAME]

B-14. Please put the following possible side effects of [DRUG NAME] in order from most likely to most unlikely based on how likely you think they are to happen to your child you. You can drag and drop the side effects to re-order them as you wish.

[Programmer: Put vertical scale across the left with “most likely” at the top and “most unlikely” at the bottom. Allow respondents to drag the side effects up and down using items from the list from B-9 so that they can order them as they wish]. For each participant, randomly assign the beginning order of the list. Make sure the list is small enough to fit on one screen.

DRAG AND DROP

FOR LOW SEVERITY PROFILE CONDITION:

• difficulty sleeping

• increased blood pressure

• rapid heartbeat

• Increased sensitivity to light

• fatigue

• nausea

• dizziness [common to high and low profile]

• dry mouth [bogus – not in ad]

• nervousness [bogus – not in ad]

FOR HIGH SEVERITY PROFILE CONDITION:

• an abrupt decrease in night vision

• liver failure

• suicidal thoughts or actions

• seizures/convulsions

• hair loss

• deafness

• dizziness [common to high and low profile]

• dry mouth [bogus – not in ad]

• nervousness [bogus – not in ad]

[SECTION C: Intentions and Information Seeking Behavior]

C-1. Based on the advertising, please rate how likely or unlikely you are to do each of the following behaviors:

GRID SC PER ROW

[RANDOMIZE ORDER]	1 very unlikely	2 unlikely	3 somewhat unlikely	4 neither unlikely nor likely	5 somewhat likely	6 likely	7 very likely
a. Ask your child’s doctor for more information about [DRUG NAME].
b. Look for information about [DRUG NAME] on the Internet.
c. Talk with a friend or family member about [DRUG NAME].
d. Ask your child’s doctor to prescribe [DRUG NAME].
e. Allow your child to take [DRUG NAME] if your child’s doctor prescribed it.
f. Take [DRUG NAME] if your doctor prescribed it.
g. Talk to your parents about [DRUG NAME].
h. Ask your parents to take you to the doctor to get [DRUG NAME].

C-2. What would most affect your decision about whether or not your child would to take [DRUG NAME]?

SC

the severity of the side effects

the benefits of taking the drug

when the side effects would start

when the benefits would start

C-3. Do you think [DRUG NAME] would be covered by your family’s health insurance?

SC

no; not at all

yes; partially

yes; completely
I do My family does not have health insurance

I don’t know

[SECTION D: Additional Potential Moderators]

D1-D3: ASK ONLY OF PARENTS AND ADOLESCENTS

INFONODE: The following section will ask questions about your child, [CHILD NAME] [PARENT RELATIONSHIP], who signed you up for this study

D-1. Who would make the final decision about whether your child you would use this drug?

SC

you

your child [PARENT RELATIONSHIP]

you and your child [PARENT RELATIONSHIP] together

D-3.

INFONODE: Please select one answer per question.

GRID SC PER ROW

	Always	Often	Sometimes	Rarely	Never
I let my child My [PARENT RELATIONSHIP] lets me decide what prescription medication he/she I should or shouldn’t take.
I ask my child’s My [PARENT RELATIONSHIP] asks me my preference when we discuss taking different prescription medications.

INFONODE: For the following questions think about when your your child’s [MEDICAL CONDITION] was at its worst.

D-6. I sometimes feel like my child is I’m treated differently because of his/her my [MEDICAL CONDITION].

SC

strongly disagree

disagree

somewhat disagree

neither agree nor disagree
somewhat agree
agree

strongly agree

D-8. How often does your child do you feel embarrassed about his/her your [MEDICAL CONDITION]?

SC

always

often

sometimes

rarely

never

D-9. How often does your child do you feel ashamed that he/she has you have [MEDICAL CONDITION]?

SC

always

often

sometimes

rarely

never

INFONODE: Please select one answer per question.

D-10.

GRID SC PER ROW

[RANDOMIZE ORDER]	1 strongly disagree	2 disagree	3 somewhat disagree	4 neither agree nor disagree	5 somewhat agree	6 agree	7 strongly agree
a. My child does I do not feel comfortable taking chances.
b. Before my child makes I make a decision, he/she likes I like to be absolutely sure how things will turn out.
c. My child feels I feel nervous when he/she has I have to make decisions in uncertain situations.

D-11. When did you first realize that your child you had [MEDICAL CONDITION]?

SC

six months ago or less

more than six months ago but less than a year ago

a year ago or more but less than 5 years ago

five years ago or longer

D-12. How much does your child’s [MEDICAL CONDITION] affect his/her your daily life now?

SC

not at all

some
a lot

D-13. When your child’s [MEDICAL CONDITION] was at its worst, how much did it affect his/her your daily life?

SC

not at all

some
a lot

D-14. Is your child Are you currently taking prescription medication for [MEDICAL CONDITION]?

SC

[Prescription medication is something you can only get if you have a prescription from your doctor or health care provider.]

yes

no [SKIP TO D-16]

ASK IF D-14=YES

D-15. About how long has your child have you been on his/her your current prescription medication for [MEDICAL CONDITION]?
OE NUM

__ __ [DROP DOWN: days[0-6]/weeks[0-3]/months[0-11]/years[0-18]] [SKIP TO D-17]

ASK IF D-14=NO

D-16. Has your child Have you ever taken prescription medication for [MEDICAL CONDITION]?

SC

yes

no

D-17 Have you Has your child ever had side effects from taking prescription medications?

yes

no

ASK IF D-17=YES

D-18 How serious were these side effects?

not at all serious

somewhat serious

very serious

D-20. [ADHD group only]

INFONODE: Please select one answer per question.

GRID SC PER ROW

	Never	Rarely	Sometimes	Often	Very Often
How often does your child do you have trouble wrapping up the final details of a project, once the challenging parts have been done?
How often does your child do you have difficulty getting things done in order when he/she has you have to do a task that requires organization?
How often does your child do you have problems remembering appointments or obligations?
When your child has you have a task that requires a lot of thought, how often does he/she do you avoid or delay getting started?
How often does your child do you fidget or squirm with his/her your hands or feet when he/she has you have to sit down for a long time?
How often does your child do you feel overly active and compelled to do things, like he/she you were driven by a motor?

D-21. [Acne group only]

INFONODE: Please select one answer per question.

	Not at all	Very little	Somewhat	A fair amount	A great deal
In the last month, how much was your face or neck affected by breakouts of acne?
In the last month, how much was your chest or back affected by breakouts of acne?

D-22. For each question, decide which sort of person your child you is are most like — the one on the right or the one on the left. Then decide if that is “sort of true” or “really true” for your child you. For each line mark only ONE of the four choices.

GRID SC PER ROW

	Really True for My Child Me	Sort of True for My Child Me				Sort of True for My Child Me	Really True for My Child Me
a.	❏	❏	Some people like to plan things out one step at a time	BUT	Other people like to jump right into things without planning them out beforehand	❏	❏
b.	❏	❏	Some people spend very little time thinking about how things might be in the future	BUT	Other people spend a lot of time thinking about how things might be in the future	❏	❏
c.	❏	❏	Some people like to think about all of the possible good and bad things that can happen before making a decision	BUT	Other people don’t think it’s necessary to think about every little possibility before making a decision	❏	❏
d.	❏	❏	Some people usually think about the consequences before they do something	BUT	Other people just act – they don’t waste time thinking about the consequences	❏	❏
e.	❏	❏	Some people would rather be happy today than take their chances on what might happen in the future	BUT	Other people will give up their happiness now so that they can get what they want in the future	❏	❏
f.	❏	❏	Some people are always making lists of things to do	BUT	Other people find making lists of things to do a waste of time	❏	❏
g.	❏	❏	Some people make decisions and then act without making a plan	BUT	Other people usually make plans before going ahead with their decisions	❏	❏
h.	❏	❏	Some people would rather save their money for a rainy day than spend it right away on something fun	BUT	Other people would rather spend their money right away on something fun than save it for a rainy day	❏	❏
i.	❏	❏	Some people have trouble imagining how things might play out over time	BUT	Other people are usually pretty good at seeing in advance how one thing can lead to another	❏	❏
j.	❏	❏	Some people don’t spend much time worrying about how their decisions will affect others	BUT	Other people think a lot about how their decisions will affect others	❏	❏
k.	❏	❏	Some people often think what their life will be like 10 years from how	BUT	Other people don’t even try to imagine what their life will be like in 10 years	❏	❏
l.	❏	❏	Some people think that planning things out in advance is a waste of time	BUT	Other people think that things work out better if they are planned out in advance	❏	❏
m.	❏	❏	Some people like to take big projects and break them down into small steps before starting to work on them	BUT	Other people find that breaking projects down into small steps isn’t really necessary	❏	❏
n.	❏	❏	Some people take life one day at a time without worrying about the future	BUT	Other people are always thinking about what tomorrow will bring	❏	❏
o.	❏	❏	Some people think it’s better to run through all the possible outcomes of a decision in your mind before deciding what to do	BUT	Other people think it’s better to make up your mind without worrying about things you can’t predict	❏	❏

D-23.

INFONODE: Please select one answer per question.

GRID SC PER ROW

	rarely/never	not usually	very often	almost always
My child plans I plan what he/she has I have to do.
My child does I do things without thinking.
My child makes I make up his/her my mind quickly.
My child is I am carefree and happy-go-lucky.
My child doesn’t I don’t pay attention.
My child’s mind races, and his/her my thoughts change quickly from one thing to another.
My child plans his/her I plan my spare time.
My child is I am able to control himself/herself myself.
My child concentrates I concentrate easily.
My child saves his/her I save my money rather than spend it right away.
My child I can’t sit still during movies or when he/she has I have to listen to people talk for a long time.
My child likes I like to think carefully about things.
My child tries I try to plan for his/her my future.
My child says I say things without thinking.
My child likes I like to think about complicated problems.
My child changes his/her I change my mind about what he/she likes I like to do.
My child acts I act "on impulse", doing whatever comes into his/her my mind first.
My child gets I get easily bored when he/she has I have to figure out problems.
My child acts before he/she thinks. I act before I think.
My child is I am a careful thinker.
My child changes his/her friends often. I change my friends often.
My child buys I buy things without thinking about whether he/she needs I need them.
My child I can only think about one problem at a time.
My child changes I change the things he/she likes I like to do a lot.
My child spends I spend more money than he/she I should.
When my child thinks I think about one thing, other thoughts pop up in his/her my mind.
My child is I am more interested in what's happening now than in the future.
My child finds I find it hard to concentrate when he/she has I have to listen to people talk for a long time.
My child likes I like to solve games and puzzles.
My child likes I like to think about how my life will be in the future.

D-24. What is your birthdate?

OD NUM (MONTH/DAY/YEAR)

___ ___/__ ___ / __ __ __ __

RANGE YEAR: 1900-2014

D-24B. What is your child’s birthdate?

OD NUM (MONTH/DAY/YEAR)

___ ___/__ ___ / __ __ __ __

RANGE YEAR: 1900-2014

D-25. What is your gender?

SC

male

female

D-25B. What is your child’s gender?

SC

male

female

D-26. How would you describe your race?

SC

American Indian / Alaskan Native
Asian
black or African American
Native Hawaiian / Pacific Islander
white
other

D-26B. How would you describe your child’s race?

SC

American Indian / Alaskan Native
Asian
black or African American
Native Hawaiian / Pacific Islander
white
other

D-27. Are you Hispanic or Latino?

SC

yes
no

D-27B. Is your child Hispanic or Latino?

SC

yes
no

D-28. What is the highest level of education you have completed?

SC

less than high school

[IF LESS THAN HIGH SCHOOL, ASK] last grade completed: [drop down menu with all grades 1-12]

high school graduate or GED

some college or technical school (no degree)

college (2-year) degree

College (4-year) degree

Some graduate school (no degree)

Graduate school degree (MBA, PhD, etc.)

D-29. Please enter the 5-digit zip code where your home or residence is located.

OE NUM – VALIDATE 5 DIGIT ZIP CODE

__________

D-30. When you are prescribed a new medication, how often do you read the risk information included in the instructions or pamphlets that come with your medication?

SC

always

often

sometimes

rarely

never

[CONTINUE IF NOT “NEVER”, OTHERWISE SKIP TO D-32]

ASK IF D30≠NEVER

D-31. When you read instructions or pamphlets from your doctor or pharmacy, how much do you understand?

none

not much

only a little bit

some
a lot
everything

ASK ALL D-32. When you see print ads for prescription medications, like in a magazine, how often do you read the information about the risks?

always

often

sometimes

rarely

never

I have never seen print ads for prescription medications

ASK ALL D-33. When you hear ads for prescription medications, like on the radio, how often do you pay attention to the information about the risks?

always

often

sometimes

rarely

never

I have never heard ads for prescription medications

OMB Control No. _____. Expires _________.