Form Approved
OMB No. XXXX-xxxx
Exp. Date xx/xx/xxxx
Evaluation of the Fresh Empire Campaign on Tobacco- Web Screener (EFECT-S)
Subjects for Questionnaire:
Section S: Study Screener
S1. How old are you?
1 Younger than 13 -- STOP. SKIP TO S8.
2 13 years old
3 14 years old
4 15 years old
5 16 years old
6 17 years old
7 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 ____
S6. What is your zip code?
3 Don’t know
9 Prefer not to answer
S7. What county do you live in?
[DROP DOWN MENU BASED ON ZIP]
3 Don’t know
9 Prefer not to answer
S10. What is your first name?
S10_a. [IF ELIGIBLE] You are eligible to take part in a study conducted by the U.S. Food and Drug Administration. This survey will take about 20 minutes to complete. The survey will ask questions about your experiences at home and at school, as well as about your knowledge and attitudes about tobacco. Everyone who completes the online survey will receive a $25 virtual gift card by email.
We need your parent’s/guardian’s permission for you to take the survey. Your parent/guardian will not be able to see any of your answers to the questions.
Please provide the information below. If your parent/guardian gives their permission for you to take the survey, we will email the survey link to you.
Parent/Guardian Name ___________________
Phone Number __________________________
Your email address ______________________
(If you do not have an email address, please enter the address of someone in your family)
S10b. [IF NOT ELIGIBLE] Thank you for your time and responses.
Thank you for your time.
Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 5 minutes per response to complete the web 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 |
| Author | Lee, Youn |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |