Att H1_Data Collection Checklist

Form Approved

OMB No.0920-XXXX

Exp.Date xx/xx/20xx

Active Permission Jurisdiction

Pre-Administration Materials for Teachers

2017 National Youth Tobacco Survey Pilot

Dear Teacher:

Thank you for agreeing to participate in the National Youth Tobacco Survey (NYTS) Pilot, sponsored by the Centers for Disease Control and Prevention (CDC). The pilot study will be conducted in parallel to the National Youth Tobacco Survey (NYTS), and will examine the feasibility of transitioning from a paper-and-pencil questionnaire to a tablet-based administration. Transitioning to a computer based survey may reduce respondent burden in the future.

We appreciate your school's graciousness in hosting the 2017 NYTS. Your class was randomly selected to participate and cannot be replaced. We have enclosed a variety of materials to help you understand the NYTS, including the Summary of School Arrangements Form, instructions to be read when distributing permission forms, parental permission forms, survey fact sheet, reminder forms, and a Data Collection Checklist. If requested, parental permission forms are provided in Spanish. A copy of the questionnaire is available with your school’s contact person, if you would like to view it.

The enclosed Data Collection Checklist should be used to track and record the return of all parental permission forms. Names or ID’s for all students in your selected class should be listed on this checklist, not just those participating in the survey. Parental permission must be indicated in the parental permission for a student to be eligible in the survey. Names will be kept confidential and destroyed after the completion of data collection. The names are needed to take roll, make sure students not in the selected class do not “slip in,” identify students eligible to complete the survey (i.e., returned parental permission form with a “yes” response), develop make-up lists of eligible students who are absent, and determine the gender and grade of all nonparticipants. This form needs to be filled out BEFORE the data collection date.

You play a very important role in the survey. Your support and encouragement are necessary to ensure a high rate of participation among your students. A high participation rate is needed to produce valid national estimates of health risk behaviors.

Please follow the instructions below to help us prepare for a successful survey administration in your class.

1. Distribute the parental permission forms to students in the selected class as soon as possible, preferably at least 7 days prior to the survey date. Encourage students to return the forms the next day.

2. Give a reminder form and/or another parental permission form to students as needed.

3. Track and record the return of all permission forms on the Data Collection Checklist. Our data collector will meet with you immediately prior to the survey administration to review the checklist. NOTE: Returned parental permission forms remain at the school.

4. On the day of the survey, please plan an alternate activity for those students who do not have parental permission to take the survey (i.e., returned the form with a “no” response).

Survey procedures have been designed to protect your students’ privacy and allow for anonymous participation. During survey administration, you will be asked to remain at the front of the classroom to increase student candor. The survey will be administered by specially trained field staff. It will take less than one class period.

The participation of your students in the NYTS Pilot will help the CDC, educators, and public health officials assess and improve efforts to reduce tobacco use among adolescents throughout the nation. If you have any questions please feel free to contact our representative at 800-675-9727 or you may contact Linda J. Neff, at CDC. Her number is (770) 488-8674. Thank you again for your cooperation.

Sincerely,

Linda Neff,

Office of Smoking and Health

Data Collection Checklist:

2015 NYTS Pilot DATA COLLECTION CHECKLIST

School Name: ____________________________________________ Date of Survey Administration: _____________________ Teacher: __________________________________ Grade(s): _____ Class: ______________________ Period: ______

Please Print Student Name or Identifier	Date Reminder Sent	Check if Permission Form was Returned “No”	Check if Permission Form was Returned “Yes”	If Student Did NOT Participate Please list reason
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including 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: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30333, ATTN:PRA

Passive Permission Jurisdiction

Pre-Administration Materials for Teachers

2017 National Youth Tobacco Survey Pilot

Dear Teacher:

Thank you for agreeing to participate in the National Youth Tobacco Survey (NYTS) Pilot, sponsored by the Centers for Disease Control and Prevention (CDC). The pilot study will be conducted in parallel to the National Youth Tobacco Survey (NYTS), and will examine the feasibility of transitioning from a paper-and-pencil questionnaire to a tablet-based administration. Transitioning to a computer based survey may reduce respondent burden in the future.

We appreciate your school's graciousness in hosting the 2017 NYTS Pilot. Your class was randomly selected to participate and cannot be replaced. We have enclosed a variety of materials to help you understand the NYTS, including the Summary of School Arrangements Form, instructions to be read when distributing permission forms, parental permission forms, survey fact sheet, reminder forms, and a Data Collection Checklist. If requested, parental permission forms are provided in Spanish. A copy of the questionnaire is available with your school’s contact person, if you would like to view it.

The enclosed Data Collection Checklist should be used to track and record the return of any parental permission forms returned to you. Names or ID’s for all students in your selected class should be listed on this checklist, not just those participating in the survey. Parental permission forms do not need to be received for a student to have permission to take the survey. If a parental permission is returned and indicates a student does not have parental permission they are not eligible to take the survey. Names will be kept confidential and destroyed after the completion of data collection. The names are needed to take roll, make sure students not in the selected class do not “slip in,” identify students eligible to complete the survey (i.e., returned parental permission form with a “yes” response), develop make-up lists of eligible students who are absent, and determine the gender and grade of all nonparticipants. This form needs to be filled out BEFORE the data collection date.

You play a very important role in the survey. Your support and encouragement are necessary to ensure a high rate of participation among your students. A high participation rate is needed to produce valid national estimates of health risk behaviors.

Please follow the instructions below to help us prepare for a successful survey administration in your class.

5. Distribute the parental permission forms to students in the selected class as soon as possible, preferably at least 7 days prior to the survey date. Encourage students to return the forms the next day.

6. Give a reminder form and/or another parental permission form to students as needed.

7. Track and record the return of all permission forms on the Data Collection Checklist. Our data collector will meet with you immediately prior to the survey administration to review the checklist. NOTE: Returned parental permission forms remain at the school.

8. On the day of the survey, please plan an alternate activity for those students who do not have parental permission to take the survey (i.e., returned the form with a “no” response).

Survey procedures have been designed to protect your students’ privacy and allow for anonymous participation. During survey administration, you will be asked to remain at the front of the classroom to increase student candor. The survey will be administered by specially trained field staff. It will take less than one class period.

The participation of your students in the NYTS will help the CDC, educators, and public health officials assess and improve efforts to reduce tobacco use among adolescents throughout the nation. If you have any questions, please call Linda J. Neff at 770-488-8674. Thank you again for your cooperation.

Sincerely,

Linda Neff,

Office of Smoking and Health

Data Collection Checklist:

2015 NYTS Pilot DATA COLLECTION CHECKLIST

School Name: ____________________________________________ Date of Survey Administration: _____________________ Teacher: __________________________________ Grade(s): _____ Class: ______________________ Period: ______

Please Print Student Name or Identifier	Date Reminder Sent	Check if Permission Form was Returned “No”	Check if Permission Form was Returned “Yes”	If Student Did NOT Participate Please list reason
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including 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: CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30333, ATTN:PRA