Form 0920-0572 Crisis Next Door Screener

Form Approved

OMB No. 0920-0572

Exp. Date 8/31/2021

To determine if you are eligible for the study, we’d like to ask you three questions.

[SCREEN #1]

SC1. What is your age? __________

If SC1 >30 and <50, Eligible.

If SC2 <30 OR if SC2 > 50, go to ineligibility statement.

[SCREEN #2]

SC2. Have you seen, heard or read any TV or online advertising about The Crisis Next Door campaign?

• Yes [Go to SC3]

• No

• Don’t Know/Not Sure

• Refused [GO TO INELIGIBILITY STATEMENT]

[SCREEN #3]

SC3. I feel confident The Crisis Next Door campaign is about…. [SELECT ONE]

[RANDOMIZE RESPONSE OPTIONS]

• Domestic violence

• Rebuilding after hurricanes and tornados

• The opioid epidemic

• Teen suicide

• I’m not sure

If SC2 = Yes or Don’t Know/Not Sure and SC3 = THE OPIOID EPIDEMIC, GO TO INELIGIBLE STATEMENT. ELSE, CONTINUE.

[SCREEN #4]

SC4. What is your sex?

• Female

• Male

[SCREEN #5]

SC5. Are you of Hispanic, Latino/a, or Spanish origin?

• Yes

• No

[SCREEN #6]

SC6. Which of the following best describes your race (select all that apply)?

• White

• Black or African American

• American Indian or Alaska Native

• Asian

• Native Hawaiian or Other Pacific Islander

[SCREEN #7]

SC7. What is your annual household income?

• Less than $25,000

• $25,000 to $49,999

• $50,000 to $74,999

• $75,000 to $99,999

• $100,000 to $149,999

• $150,000 to $199,999

• $200,000 to $249,999

• $250,000 or more

• Prefer not to answer

[SCREEN #8]

SC8. What is the highest level of education you have achieved?

• Less than High School

• High School

• Some college but no degree

• Associate Degree

• 4 Year College Degree

• Graduate or Doctorate Degree

• Prefer not to answer

Ineligibility Statement. Thank you for participating in this short survey. We appreciate your time and responses.

Public reporting burden of this collection of information as 2 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, SD-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0572).