3-New PATH Validation Form

Population Assessment of Tobacco and Health (PATH) Study (NIDA)

Attachment 24
PATH Study
Validation Form
May 7, 2015

PATH Study Validation Form
Intro_A.
Hello, my name is and I am calling on behalf of the Population Assessment of Tobacco and Health
(PATH) Study. May I please speak with < SP NAME>?



1.

(IF YOU ARE SPEAKING WITH THE SP….CONTINUE TO Q1)
(IF SP IS CALLED TO THE PHONE….INTRODUCE YOURSELF AGAIN
AND CONTINUE TO Q1)



(IF SP IS NOT AVAILABLE….GO TO END_B)



(IF NO SUCH PERSON AT PHONE NUMBER….GO TO END_A)

Just to confirm, am I speaking with < NAME>?
☐YES ............................ 1
(GO TO Q2)
☐NO .............................. 2

2.

3.

(GO TO END_B)

Recently one of our interviewers visited your address to conduct an interview as part of the Population
Assessment of Tobacco and Health (PATH) Study. Do you remember talking to him or her?
☐YES ............................ 1

(SKIP TO Q7)

☐NO .............................. 2

(GO TO Q3)

During the interview, you were asked questions about your health and tobacco use. Do you remember the visit
now?
☐YES ............................ 1

(SKIP TO Q7)

☐NO .............................. 2

(GO TO Q4)

Public reporting burden for this collection of information is estimated to average 4 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0664). Do not return the completed form to this
address.

4.

5.

On did you live at ?
☐YES ............................ 1

(SKIP TO Q6)

☐NO .............................. 2

(GO TO Q5)

When did you move to this address?
___________________________________________________________________ (GO TO END_D)

6.

7.

8.

Perhaps there is a mistake. I’d like to make sure that I dialed correctly. Is this ?
☐YES ............................ 1

(GO TO END_D)

☐NO .............................. 2

(GO TO END_A)

On all of our studies, we routinely re-contact some people who were interviewed to make sure our interviewers
are following procedures correctly. My questions today will take only a few minutes. Is this a good time for you?
☐YES ............................ 1

(GO TO Q8)

☐NO .............................. 2

(GO TO END_C)

Please know that information from our call today will be kept private and used only for the PATH Study.
(CONTINUE TO Q9)

9.

During the visit, was the interviewer polite and courteous?
☐YES ........................... 1

(CONTINUE)

☐SOMEWHAT ............. 2

(CONTINUE)

☐NO ............................. 3

(CONTINUE)

☐DON’T RECALL ........ 4

(CONTINUE)

☐REFUSED …..…….… 5

(CONTINUE)

On the day of the interview, approximately how long would you say the visit lasted?

☐LESS THAN 15 MINUTES...................................... 1

(CONTINUE)

☐BETWEEN 15 MINUTES TO 30 MINUTES............ 2

(CONTINUE)

☐BETWEEN 31 MINUTES TO 60 MINUTES............ 3

(CONTINUE)

☐LONGER THAN ONE HOUR…………………..…. . 4

(CONTINUE)

☐DON’T RECALL…………….………………………... 5

(CONTINUE)

☐REFUSED…………………………………………..… 6

(CONTINUE)

10. Did the interviewer give you a copy of our consent document to read? This was a document that included
information about the PATH Study and discussed your consent to participate in an interview.
☐YES ............................ 1
☐NO .............................. 2

(CONTINUE)
(CONTINUE)

☐DON’T RECALL…....... 3

(CONTINUE)

☐REFUSED………..........4

(CONTINUE)

11. For part of the visit, did the interviewer turn the laptop towards you and ask you to read the questions to yourself
and enter your answers directly into the laptop?
☐YES ............................ 1
☐NO .............................. 2

(CONTINUE)
(CONTINUE)

☐DON’T RECALL.......... 3

(CONTINUE)

☐REFUSED…….…....... 4

(CONTINUE)

12. Did the interviewer give you a new debit card or tell you that a new payment will be added to your existing PATH
debit card to thank you for your participation?
☐YES ............................ 1
☐NO .............................. 2

(CONTINUE)
(CONTINUE)

☐DON’T RECALL.......... 3

(CONTINUE)

☐REFUSED…….…....... 4

(CONTINUE)

13. During the most recent visit, did the interviewer ask for your permission to collect a urine sample?
☐YES ............................ 1
☐NO .............................. 2

(CONTINUE)
(CONTINUE)

☐DON’T RECALL.......... 3

(CONTINUE)

☐REFUSED………........ 4

(CONTINUE)

14. Did you give a urine sample?
☐YES ............................ 1
☐NO .............................. 2

(CONTINUE)
(CONTINUE)

☐DON’T RECALL…....... 3

(CONTINUE)

☐REFUSED………......... 4

(CONTINUE)

15. During the most recent visit, did the interviewer ask for your permission to let a health professional visit to
collect blood?
☐YES……………………………..... 1
☐NO…………………......................2

(CONTINUE TO BOX A)
(CONTINUE TO BOX A)

☐DON’T RECALL...........................3

(CONTINUE TO BOX A)

☐REFUSED……….........................4

(CONTINUE TO BOX A)

Box A
Routing Instructions:
IF Blood Collection visit was completed, GO TO Q17.
OTHERWISE, SKIP TO Q18.

16. During the visit by the health professional who collected the blood sample, was the health professional polite
and courteous?
☐YES ..........................................................1

(CONTINUE)

☐SOMEWHAT……………………………….2

(CONTINUE)

☐NO ...........................................................3

(CONTINUE)

☐BLOOD DRAW NOT TAKEN...................4

(CONTINUE)

☐DON’T RECALL.......................................5

(CONTINUE)

☐REFUSED……….....................................6

(CONTINUE)

17. Would you like to tell me anything else about the interviewer?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
___________________________________________________________________________ (CONTINUE)

18. What is your current address?
_[ADDRESS 1]_______________________________________________________
_ [ADDRESS 2]_______________________________________________________
_[CITY/STATE/ZIP]_______________________________________ (CONTINUE)
☐REFUSED………........................... 2

(GO TO END_E)

19. VALIDATOR INSTRUCTIONS. DO NOT READ TO RESPONDENT.
WAS THE ADDRESS PROVIDED ON THE PREVIOUS QUESTION THE SAME ADDRESS AS BELOW? CODE AS
“YES” IF ADDRESS IS SIMILAR. DOES NOT HAVE TO BE AN EXACT MATCH.
___________________________________
☐YES…………………………....... 1
☐NO………………........................ 2

(GO TO END_E)
(CONTINUE TO Q21)

☐NOT SURE …….….................... 3

(CONTINUE TO Q21)

20. Did the interviewer visit you at this address to conduct the interview?
☐YES……………………………........ 1
☐NO…………………........................ 2

(GO TO END_F)
(CONTINUE TO Q22)

☐DON’T RECALL............................. 3

(GO TO END_F)

☐REFUSED………........................... 4

(GO TO END_F)

21. At what address did the interviewer visit you to conduct the interview?
_[ADDRESS 1]_______________________________________________________
_ [ADDRESS 2]_______________________________________________________
_[CITY/STATE/ZIP]_______________________________________ (CONTINUE TO Q23)
☐REFUSED………........................... 2

(GO TO END_F)

22. VALIDATOR INSTRUCTIONS. DO NOT READ TO RESPONDENT.
WAS THE ADDRESS PROVIDED ON THE PREVIOUS QUESTION THE SAME ADDRESS AS BELOW? CODE AS
“YES” IF ADDRESS IS SIMILAR. DOES NOT HAVE TO BE AN EXACT MATCH.
___________________________________
☐YES……………………………..... 1
☐NO…………………......................2
☐NOT SURE …….…......................3

(GO TO END_E)
(GO TO END_F)
(GO TO END_E)



IF QUESTIONS ARE ASKED, PLEASE REFER SP TO THE PATH SUPPORT DESK AT 1-888-311-1819.



GO TO END_E

END_A: I apologize. I have the wrong number. Thank you. Goodbye.

END_B: Thank you for your time. What is a good day and time to reach < SP NAME>? What phone number is best to use?
DATE: _____________________
TIME: _________

am

pm

PHONE NUMBER: _____________________
☐ REFUSED FURTHER CONTACT
Thank you. Goodbye.

END_C: What is a good day and time to reach you again?
DATE: _____________________
TIME: _________

am

pm

PHONE NUMBER: _____________________
☐ REFUSED FURTHER CONTACT
Thank you. Goodbye.

END_D: Thank you for your time. There seems to be a problem with some of our information. I will check our records and
someone may call you back.
Thank you. Goodbye.

END_E: Those are all the questions I have. Thank you so much for your time today. Goodbye.

END_F: Those are all the questions I have. Thank you so much for your time today. Goodbye.
PROGRAMMER NOTE: SET RESULT CODE TO VR (Validation Risk)
[PLEASE READ THE FOLLOWING MESSAGE INTO THE ANSWERING MACHINE.]
Hello, I'm calling on behalf of the Population Assessment of Tobacco and Health Study, PATH. We'd like a few minutes of
's time to verify some information (he/she) provided. We will call back another time or you may call us
at 1-877-709-5807.