Questionnaire Administration Script

Form Approved

OMB No. 0920-0621

Exp. xx/xx/XXXX

DATA COLLECTOR SURVEY ADMINISTRATION SCRIPT

NATIONAL YOUTH TOBACCO SURVEY

STEP 1 - VERIFY THAT ALL ASSEMBLED STUDENTS HAVE COMPLETED APPROPRIATE PERMISSION FORM PROCESS REQUIRED FOR THIS SCHOOL AND THAT NONPARTICIPATING STUDENTS (IF ANY) HAVE AN ALTERNATE ACTIVITY.

STEP 2 - AFTER STUDENTS ARE SEATED, DISTRIBUTE (OR ASK TEACHERS TO DISTRIBUTE) PENCILS AND STUDENT ENVELOPES. DO NOT DISTRIBUTE SURVEY BOOKLETS.

STEP 3 - INTRODUCE YOURSELF AND THE SURVEY TO THE CLASS.

I’d like to thank each of you for participating in the National Youth Tobacco Survey today. This survey is being conducted on behalf of the Centers for Disease Control and Prevention (also known as CDC). Participating in this survey is voluntary and your grade in this class will not be affected, whether or not you answer the questions. You may skip any questions you do not wish to answer. However, only a limited number of students like yourselves are participating in this survey in schools all over the Nation. The answers you give are very important so the results are accurate.

I would like to emphasize that this is not a test of you or this school. In order to help develop better education programs, educators and health officials must collect comprehensive data on the attitudes, knowledge, and behaviors of middle and high school students (grades 6‑12) with respect to tobacco, and on other influences that might make a youth susceptible to tobacco use in the future.

STEP 4 - DISTRIBUTE SURVEY BOOKLETS. EMPHASIZE PRIVACY/ ANONYMITY.

Throughout the entire survey process, we will maintain strict procedures to protect your privacy and allow for your anonymous participation. Because the survey is anonymous, no one will know your answers. Please do not write your name on the survey booklet or envelope. Your answers are private and we do not want to know your name. Results of this survey will never be reported by names, class, or school. When you finish the survey, place your survey booklet in the envelope provided, seal it, and leave it on your desk.

PAUSE HERE TO ANSWER ANY QUESTIONS...

STEP 5 - INSTRUCT THE CLASS IN FILLING OUT SURVEY.

Now I would like you to look at the survey booklet. Please take a moment to read the instructions on the front cover of the survey booklet.

(PAUSE)

Use the No. 2 pencil you have been given to fill out this survey. Do not use a pen or some other pencil. You make keep the pencil that was provided. Notice that for each question on the survey, there is a corresponding set of ovals. For each question, choose the answer that best fits what you know, believe, or do, then fill in the corresponding oval. If you must change an answer, erase your old answer completely.

When you are finished, look over your booklet to make sure that you haven’t skipped any questions you wanted to answer. We have allowed 35 minutes for completing the survey but you may stop at any time. If you finish before that time, place your survey booklet in the envelope, seal it, and stay seated until I ask you to turn it in. It is important that you answer the questions based on what you really know, believe, and do. Don’t pick a response just because you think that’s what someone wants you to say. Your teacher and I are not allowed to answer any questions. Simply do the best that you can. Please begin.

NOTE TO DATA COLLECTOR:

(DO NOT READ ALOUD TO STUDENTS)

While students are taking the survey, work with the teacher to complete the Data Collection Checklist, Make-up list, and fill out the label on the front of the 12x15 class envelope. Remember when calculating the enrollment, please do not count students who are on the rolls but for all practical purposes have dropped out, are on suspension, or are on extended medical absence. Please write down the number of booklets enclosed.

STEP 6 - AT THE END OF CLASS PERIOD, COLLECT SURVEYS.

STEP 7 - THANK PARTICIPANTS.

The CDC would like to thank all of you for participating in this survey. The information you have provided will be used to develop better health education programs for students like yourselves all around the Nation. If you have any questions related to the topics on the survey, please contact: ________________________. You may keep the pencil.

STEP 8 - THANK THE TEACHER.