Media Tracking Screener

Attachment 4_E2a3: Youth Media Tracking SCREENER

Form Approved

OMB No. 0910-0753

Exp. Date 09/30/2019

Evaluation of the Public Education Campaign on Teen Tobacco-Media Tracking (ExPECTT-MT)

S1. How old are you?

₁ 11 years old or younger (GO TO CLOSING TEXT)

₂ 12 years old (GO TO CLOSING TEXT)

₃ 13 years old (GO TO A1)

₄ 14 years old (GO TO A1)

₅ 15 years old (GO TO A1)

₆ 16 years old (GO TO A1)

₇ 17 years old (GO TO A1)

₈ 18 years old or older (GO TO CLOSING TEXT)

₉ Prefer not to answer (GO TO CLOSING TEXT)

ASK: All respondents

CLOSING TEXT “You do not qualify for this survey, which is for children ages 13 to 17. Thank you very much for your response.“

C1. Are you male or female?

₁ Female

₂ Male

₉ Prefer not to answer

ASK: All respondents

C2. Are you Hispanic, Latino/a, or of Spanish origin?

₁ No, not of Hispanic, Latino/a, or Spanish origin

₂ Yes, Mexican American, Chicano/a

₃ Yes, Puerto Rican

₄ Yes, Cuban

₅ Yes, another Hispanic, Latino/a, or Spanish origin

₉ Prefer not to answer

ASK: All respondents

C3. What race or races do you consider yourself to be? Please select 1 or more of these categories.

	1 Yes
C3_1. White	1
C3_2. Black or African American	1
C3_3. American Indian or Alaska Native	1
C3_4. Asian Indian	1
C3_5. Chinese	1
C3_6. Filipino	1
C3_7. Japanese	1
C3_8. Korean	1
C3_9. Vietnamese	1
C3_10. Native Hawaiian	1
C3_11. Guamanian or Chamorro	1
C3_12. Samoan	1
C3_13. Other Asian	1
C3_14. Other Pacific Islander	1

ASK: All respondents

OMB No: 0910-0753 Expiration Date: 09/30/2019

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

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