Adolescent Screener

OMB #0910-XXXX

Expires XX/XX/XXXX

Appendix E: Screening Questionnaire

Thank you for your interest in this survey. To get started, we first need to ask you a few questions to see if you are eligible to take the survey.

SECTION SA: AGE SCREENER

SA1. How old are you?

________________ [NUMERIC TEXT FIELD, WHOLE NUMBERS ONLY]

[IF SA1 < 13, TERMINATE]

[IF SA1 ≥ 13 AND ≤ 17, GO TO YOUTH SCREENER (SB1)]

[IF SA1 ≥ 18, GO TO ADULT SCREENER (SC1)]

SECTION SB: YOUTH SCREENER

SB1. Have you ever tried cigarette smoking, even one or two puffs?

1. Yes

2. No [GO TO SB3]

SB2. In the past 30 days, have you smoked a cigarette?

1. Yes [GO TO SB7]

2. No [TERMINATE]

SB3. Have you ever been curious about smoking a cigarette? 

1. Definitely yes

2. Probably yes

3. Probably not

4. Definitely not

SB4. Do you think that in the future you might experiment with cigarettes? 

1. Definitely yes

2. Probably yes

3. Probably not

4. Definitely not

SB5. At any time during the next year, do you think you will smoke a cigarette?

1. Definitely yes

2. Probably yes

3. Probably not

4. Definitely not

SB6. If one of your best friends offered you a cigarette, would you smoke it?

1. Definitely yes

2. Probably yes

3. Probably not

4. Definitely not

[IF SB3 = 4 AND SB4 = 4 AND SB5 = 4 AND SB6 = 4, TERMINATE]

SB7. In the past 5 years, have you or any member of your household worked for any of the following?

	Yes [1]	No [2]	I don’t know [3]
SB7_1. A tobacco or cigarette company
SB7_2. A public health or community organization involved in communicating the dangers of smoking or the benefits of quitting
SB7_3. The U.S. Food and Drug Administration (FDA)

[IF SB7_1 = 1 OR SB7_2 = 1 OR SB7_3 = 1, TERMINATE]

[IF (SB7_1 = 2 OR 3) AND (SB7_2 = 2 OR 3) AND (SB7_3 = 2 OR 3) AND SB2 = 1, ASSIGN TO YOUTH SMOKER GROUP]

[IF (SB7_1 = 2 OR 3) AND (SB7_2 = 2 OR 3) AND (SB7_3 = 2 OR 3) AND (SB3 = 1, 2, OR 3) AND (SB4 = 1, 2, OR 3) AND (SB5 = 1, 2, OR 3) AND (SB6 = 1, 2, OR 3), ASSIGN TO YOUTH SUSCEPTIBLE GROUP]

SECTION SC: ADULT SCREENER

SC1. Have you smoked at least 100 cigarettes in your entire life?

1. Yes

2. No [TERMINATE]

SC2. Do you know smoke cigarettes every day, some days, or not at all?

1. Every day

2. Some days

3. Not at all [TERMINATE]

SC3. In the past 5 years, have you or any member of your household worked for any of the following?

	Yes [1]	No [2]
SC3_1. A tobacco or cigarette company
SC3_2. A public health or community organization involved in communicating the dangers of smoking or the benefits of quitting
SC3_3. The U.S. Food and Drug Administration (FDA)

[IF SC3_1 = 1 OR SC3_2 = 1 OR SC3_3 = 1, TERMINATE]

[IF SA1 ≥ 18 AND ≤ 24, ASSIGN TO YOUNG ADULT SMOKER GROUP]

[IF SA1 ≥ 25, ASSIGN TO ADULT SMOKER GROUP]

SECTION SD: DEMOGRAPHICS

SD1. What is your sex?

1. Male

2. Female

[ASK IF SA1 SA1 ≥ 18]

SD2. What is the highest level of school you have completed or the highest degree you have received?

1. Never attended school or only attended kindergarten

2. Grades 1 through 8

3. Grades 9 through 11

4. High school graduate or GED

5. Post high school training other than college (vocational or technical training)

6. Some college or 2-year degree

7. College degree (4-year degree)

8. Postgraduate degree

SD3. Are you Hispanic, Latino/a, or of Spanish origin?

1. Yes

2. No

SD4. What is your race? (One or more categories may be selected)

1. White

2. Black or African American

3. American Indian or Alaska Native

4. Asian Indian

5. Chinese

6. Filipino

7. Japanese

8. Korean

9. Vietnamese

10. Other Asian

11. Native Hawaiian

12. Guamanian or Chamorro

13. Samoan

14. Other Pacific Islander

[IF YOUTH SMOKER OR YOUTH SUSCEPTIBLE, GO TO YOUTH ASSENT]

[IF YOUNG ADULT SMOKER OR ADULT SMOKER, GO TO ADULT CONSENT]

[TERMINATE SCRIPT: You do not qualify for this survey. Thank you for your time.]

[SCRIPT IF QUESTION IS SKIPPED: It looks like you missed a question on this page. To participate in the survey, we need to know your answer to this question. Please select a response.]

Paperwork Reduction Act Statement: The public reporting burden for this information collection has been estimated to average 2 minutes per response to complete this screener survey (the time estimated to read and complete). Send comments regarding this burden estimate or any other aspects of this information collection, including suggestions for reducing burden, to [email protected].

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