Sample Data Collection Instrument - Rough Cut Testing Screen

Att. 3a. Example Data Collection Instrument_Rough Cut Testing Survey Screener.docx

Message Testing for Tobacco Communication Activities

Sample Data Collection Instrument - Rough Cut Testing Screen

OMB: 0920-0910

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Form Approved

OMB No. 0920-0910

Exp. Date 03/31/2018










National Tobacco Prevention and Control Public Education Campaign:

Rough Cut Testing of Television, Radio, Print, and Digital Advertisements for the 2016 Tips Campaign


Screener Questionnaire
















Public reporting burden of 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0910).

On behalf of the Centers for Disease Control and Prevention (CDC), we're conducting a study about health and smoking-specific advertising that you see in the media. Your opinions are very important to us! Please be assured that the purpose of this survey is to gather feedback regarding health and smoking-specific advertising. We will not report your answers individually and will only report the results from this survey for all participants combined. Thank you for taking the time to help us!


Your participation in this survey is voluntary.


Section: Screening Items


Demographic Information

{PREAMBLE}

Please indicate your race or ethnic background. Are you….?


SELECT ONE

DEMO6. Ethnicity

  1. Hispanic or Latino

  2. Not Hispanic or Latino


SELECT ONE OR MORE

DEMO7. Race:

  1. White

  1. Black or African American

  2. American Indian or Alaska Native

  3. Native Hawaiian or Other Pacific Islander

  4. Asian



{If Demo07.07 is selected}

LANGPREFAsian1: Do you speak a language other than English at home?

  1. Yes

  2. No


LANGPREFAsian2: What is this language?

  1. Chinese

  2. Korean {Redirect to English version of survey}

  3. Vietnamese {Redirect to English version of survey}

  4. Other Specify {Redirect to English version of survey}


{ LANGPREFAsian2 = 01}

LANGPREFChinese: In what language do you prefer to watch, read, and listen to media?

  1. Chinese only

  2. Chinese more than English

  3. Both Chinese and English equally

  4. English more than Chinese {Redirect to English version of survey}

  5. English only {Redirect to English version of survey}

  6. None of the above TERMINATE


{ LANGPREFAsian2 = 02,03,04}

LANGPREF2: In what language do you prefer to watch, read, and listen to media?

  1. {LANGPREFAsian2 FILL} only TERMINATE

  2. {LANGPREFAsian2 FILL} more than English TERMINATE

  3. Both {LANGPREFAsian2 FILL} and English equally {Redirect to English version of survey}

  4. English more than {LANGPREFAsian2 FILL} {Redirect to English version of survey}

  5. English only {Redirect to English version of survey}

  6. None of the above TERMINATE


DAGE1: What is your current age?

  1. Under 18 years of age {TERMINATE}

  2. 18-24 years of age

  3. 25-34 years of age

  4. 35-44 years of age

  5. 45-54 years of age

  6. 55-64 years of age {TERMINATE}

  7. 65-74 years of age {TERMINATE}

  8. 75 years of age or older {TERMINATE}

  9. Refuse to answer {TERMINATE}

DEMO5: What state do you live in?

  1. Alabama

  2. Alaska

  3. Arizona

  4. Arkansas

  5. California

  6. Colorado

  7. Connecticut

  8. Delaware

  9. Florida

  10. Georgia

  11. Hawaii

  12. Idaho

  13. Illinois

  14. Indiana

  15. Iowa

  16. Kansas

  17. Kentucky

  18. Louisiana

  19. Maine

  20. Maryland

  21. Massachusetts

  22. Michigan

  23. Minnesota

  24. Mississippi

  25. Missouri

  26. Montana

  27. Nebraska

  28. Nevada

  29. New Hampshire

  30. New Jersey

  31. New Mexico

  32. New York

  33. North Carolina

  34. North Dakota

  35. Ohio

  36. Oklahoma

  37. Oregon

  38. Pennsylvania

  39. Rhode Island

  40. South Carolina

  41. South Dakota

  42. Tennessee

  43. Texas

  44. Utah

  45. Vermont

  46. Virginia

  47. Washington

  48. West Virginia

  49. Wisconsin

  50. Wyoming

  51. District of Columbia

  52. Other


{Base = if DAGE1 = 02 & (AL (DEMO5.01) or NE (DEMO5.27))}

DAGE2. What is the year of your birth? (Please enter as YYYY)

{Open-end, Mask for YYYY}


{Terminate respondent if respondent is from AL (DEMO5.01) or NE (DEMO5.27) & is 18 or 19 years old}


Smoking Behavior – Core


{PREAMBLE}

The next questions are about cigarettes which are any roll of tobacco wrapped in paper. Below is an image of a cigarette.


{Base = All respondents}

TS1. Have you smoked at least 100 cigarettes in your entire life?

  1. Yes

  2. No

  3. Don’t know/not sure

  4. Refused

{Base = All respondents}

TS2. Do you now smoke cigarettes every day, some days, or not at all?

  1. I smoke every day

  1. I smoke on some days

  2. I do not smoke at all


{Base = All respondents}

TS3: On how many of the past 30 days did you smoke cigarettes?

Enter number: _______




Programmer Instructions:

Segments

Definition

Criteria

Smokers

Smokers

Answers TS1_1 to TS1 AND (TS2_1 or TS2_2 to TS2) AND Answers TS3 > 0

Non-Smokers

Non-Smokers

Answers TS1_2 to TS1 AND (TS2_3 to TS2) AND Answers TS3 = 0

Non-Smokers

Former Smokers

Answers TS1_1 to TS1 AND (TS2_3 to TS2) AND Answers TS3 = 0



Smoking Behavior – Electronic Vapor Products


{Base = Current Cigarette Smokers}


{PREAMBLE}

The next questions are about electronic vapor products. These are devices that usually contain a nicotine-based liquid that is vaporized and inhaled. You may also know them as e-cigarettes, vape-pens, hookah-pens, electronic hookahs (e-hookahs), electronic cigars (e-cigars), electronic pipes (e-pipes), or e-vaporizers. Some brand examples are Blu, NJOY, Vuse, MarkTen, and Starbuzz.


Smoking Behavior – Electronic Vapor Products

E1a. Have you ever used electronic vapor products, even one time?

  1. Yes

  2. No


{Base = Answers Yes to E1}

E2. Do you now use electronic vapor products …

  1. Every day

  2. Some days

  3. Not at all



Category

SCREENING LOGIC

Current Electronic Vapor Product Users

Answers 1 to E1 & 1 or 2 to E2


{GENERAL SCREEN OUT MESSAGE}

Thank you for your participation in this study. Unfortunately, your responses indicate that you do not fit the specific criteria needed for this particular study, or that we have already reached our required quota of responses from participants similar to you. We appreciate your enthusiasm for our study and hope you will join us on future surveys!


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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleOSH Media Rough Cut Survey
AuthorCarol Haney
File Modified0000-00-00
File Created2021-01-21

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