Item
|
Currently
Approved Question Text
|
Currently
Approved Responses
|
Revision
Type
|
Revised
Question Text
|
Revised
Responses
|
C4
|
When
you last tried to quit smoking, did you do any of the following?
|
Across:
Yes
No
Down:
C4_1.
Give
up cigarettes all at once
C4_2.
Gradually
cut back on cigarettes
C4_3.
Switch
completely
to electronic vapor products such as e-cigarettes,
vape-pens, hookah-pens, electronic hookahs (e-hookahs), electronic
cigars (e-cigars), electronic pipes (e-pipes), e-vaporizers, or
tank systems
C4_4.
Substitute
some of your regular cigarettes with electronic vapor products
such as e-cigarettes,
vape-pens, hookah-pens, electronic hookahs (e-hookahs), electronic
cigars (e-cigars), electronic pipes (e-pipes), e-vaporizers, or
tanksystems
C4_5.
Switch
to mild or some other brand of cigarettes
C4_6.
Use
nicotine replacements like the nicotine patch, nicotine gum,
nicotine lozenges, nicotine nasal spray, or nicotine inhaler
C4_7.
Use
medications like Wellbutrin, Zyban, buproprion, Chantix, or
varenicline
C4_8.
Get
help from a telephone quit line
C4_9.
Get
help from a website such as Smokefree.gov or CDC.gov/Tips
C4_10.
Get help from a doctor or other health professional
C4_11.
Get help from a pharmacist
|
Revision
|
When
you last tried to quit smoking, did you do any of the following?
|
Across:
1.
Yes
2.
No
Down:
C4_1.
Give
up cigarettes all at once
C4_2.
Gradually
cut back on cigarettes
C4_3.
Switch
completely
to vaping (using e-cigarettes,
vape pens, JUULs, mods, or other personal vaporizers)
C4_4.
Substitute
smoking some of your regular cigarettes with vaping (using
e-cigarettes,
vape pens, JUULs, mods, or other personal vaporizers)
C4_5.
Switch
to mild or some other brand of cigarettes
C4_6.
Use
nicotine replacements like the nicotine patch, nicotine gum,
nicotine lozenges, nicotine nasal spray, or nicotine inhaler
C4_7.
Use
medications like Wellbutrin, Zyban, buproprion, Chantix, or
varenicline
C4_8.
Get
help from a telephone quit line
C4_9.
Get
help from a website such as Smokefree.gov or CDC.gov/Tips
C4_10.
Get help from a doctor or other health professional
C4_11.
Get help from a pharmacist
C4_12.
Use a mobile App to help you quit smoking
C4_13.
Use a texting program to help you quit smoking
|
C5
|
When
you last tried to quit smoking, did any of the following motivate
you to try to quit?
|
Across:
1.
Yes
2.
No
Down:
C5_1.
A
family member or friend encouraged me to try to quit
C5_2.
Television
commercials, radio ads, or other types of advertisements that
focus on the health consequences of smoking
C5_3.
My
doctor or other health professional advised me to quit smoking
C5_4.
Workplace restrictions on smoking
C5_5.
Other,
please specify:__[text]_________
|
Revision
|
When
you last tried to quit smoking, did any of the following motivate
you to try to quit?
|
Across:
1.
Yes
2.
No
Down:
C5_1.
A
family member or friend encouraged me to try to quit
C5_2.
Anti-tobacco
television commercials, online ads or videos, radio ads, or other
types of advertisements that focus on the health consequences of
smoking
C5_3.
My
doctor or other health professional advised me to quit smoking
C5_4.
Workplace restrictions on smoking
C5_5.
Cost of cigarettes is too high
C5_6.
Other,
please specify:__[text]_________
|
C12
|
How
worried are you that smoking will damage your health in the
future?
|
1.
Not at all worried
2.
A little worried
3.
Somewhat worried
4.
Very worried
|
Deletion
|
N/A
|
N/A
|
E-Cig
Intro
|
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, Fin, and Logic.
Some examples of electronic vapor products are pictured below.
|
|
Revision
|
The
next questions are about vaping (using
e-cigarettes,
vape pens, JUULs, mods, other personal vaporizers). Vaping
products are battery-powered and produce vapor instead of smoke.
They typically use a nicotine liquid, although the amount of
nicotine can vary and some may not contain any nicotine at all.
Some common brands are JUUL, Vuse, MarkTen, Logic, and Blu.
These
questions concern electronic vaping products for nicotine use. The
use of electronic vaping products for marijuana use is not
included in these questions.
|
|
B8
|
Have
you ever used electronic vapor products, even one time?
|
1.
Yes
2.
No
|
Revision
|
Have
you ever vaped, even one time?
|
1.
Yes
2.
No
|
B8a
|
During
the past 30 days, on how many days did you use electronic vapor
products?
|
1.
0 days
2.
1 or 2 days
3.
3 to 5 days
4.
6 to 9 days
5.
10 to 19 days
6.
20 to 29 days
7.
All 30 days
|
Revision
|
During
the past 30 days, on how many days did you vape?
|
1.
0 days
2.
1 or 2 days
3.
3 to 5 days
4.
6 to 9 days
5.
10 to 19 days
6.
20 to 29 days
7.
All 30 days
|
B9
|
Do
you now use electronic vapor products…
|
1.
Every day
2.
Some days
3.
Not at all
|
Revision
|
Do
you now vape…
|
1.
Every day
2.
Some days
3.
Not at all
|
B9a
|
On
the days that you use electronic vapor products, how often do you
use them?
|
1.
Rarely
2.
Sometimes
3.
Often
4.
Very Often
|
Revision
|
On
the days that you vape, how often do you vape?
|
1.
Rarely
2.
Sometimes
3.
Often
4.
Very Often
|
B9_date
|
How
long ago did you first try an electronic vapor product?
|
1.
1 to 2 weeks ago
2.
3 to 4 weeks ago
3.
1 to 3 months ago
4.
4 to 6 months ago
5.
7 to 12 months ago
6.
More than 1 year ago
|
Deletion
|
N/A
|
N/A
|
B9a_date
|
How
long have you been using electronic vapor products every day or
some days?
|
1.
1 to 2 weeks ago
2.
3 to 4 weeks ago
3.
1 to 3 months ago
4.
4 to 6 months ago
5.
7 to 12 months ago
6.
More than 1 year ago
|
Deletion
|
N/A
|
N/A
|
B9a
|
Do
you usually use disposable electronic vapor products, rechargeable
vapor products that use cartridges, or rechargeable vapor products
that use refillable tanks?
|
Please
indicate the type of electronic vapor product that you use the
most.
1.
Disposable devices that are not rechargeable or refillable
2.
Rechargeable devices that are used with non-refillable cartridges
3.
Rechargeable devices that have small refillable cartridges for
e-liquid
4.
Rechargeable devices that have large refillable tanks for e-liquid
5.
Unknown device type
|
Revision
|
Do
you usually vape with disposable devices, rechargeable devices
that use pods or cartridges, or rechargeable devices that use
large refillable tanks?
|
Please
indicate the type of device that you vape most often.
1.
Disposable devices that are not rechargeable or refillable
2.
Rechargeable devices that use pods or cartridges, like JUULs
3.
Rechargeable devices that have large refillable tanks
4.
Unknown device type
|
B9b
|
On
average, about how many do you now use each
week?
|
_________[ENTER
NUMBER]
|
Deletion
|
N/A
|
N/A
|
|
|
|
|
|
|
B9b_1
|
When
you use your electronic vapor product, does the liquid/contents
usually contain nicotine?
|
1.
Yes
2.
No
3.
Don’t know
|
Revision
|
When
you vape, does the liquid/contents usually contain nicotine?
|
1.
Yes
2.
No
3.
Don’t know
|
B9c
|
Where
did you get or buy the electronic vapor products that you have
used?
|
B9c_1.
A
gas station or convenience store
B9c_2.
A
grocery store
B9c_3.
A
drugstore
B9c_4.
A
mall or shopping center kiosk/stand
B9c_5.
Over
the Internet
B9c_6.
A
store that sells electronic vapor products, such as a “vape
shop”
B9c_11.
Mass merchandisers or supercenters like Walmart, Target, or Costco
B9c_8.
From
a family member
B9c_9.
From
a friend
B9c_10.
Some other person that is not a family member or a friend
B9c_7.
Other, specify [text]_______[anchor]
|
Deletion
|
N/A
|
N/A
|
B9d
|
Which
of those is the main way you usually get your electronic vapor
products?
|
[Show
list of responses provided in B9c]
|
Deletion
|
N/A
|
N/A
|
B10
|
Are
any of the following a reason why you first tried/currently use
electronic vapor products?
|
B10_1.
They
cost less than other forms of tobacco
B10_2.
They
can be used in places where smoking cigarettes isn’t allowed
B10_3.
They
might be less harmful to me than regular cigarettes
B10_4.
They
might be less harmful to people around me than regular cigarettes
B10_5.
Electronic
vapor products come in flavors I like
B10_6.
Electronic
vapor products can help me quit smoking regular cigarettes
B10_7.
Electronic
vapor products can help me reduce the number of regular cigarettes
I smoke
B10_8.
Electronic
vapor products don’t smell
B10_9.
Using
an electronic vapor product feels like smoking a regular cigarette
B10_10.
Electronic vapor products don’t bother people who don’t
use tobacco
B10_11.
The advertising for electronic vapor products appeals to me
B10_12.
They help me deal with cravings to smoke
B10_13.
I have a friend or family member who suggested I use electronic
vapor products as a way to quit smoking
B10_14.
I was curious about electronic vapor products
B10_15.
Other, specify
|
Revision
|
Are
any of the following a reason why you [IF B9=3 INSERT: first tried
vaping; IF B9=1 or 2 INSERT: currently vape]?
|
B10_1.
I
can vape when or where smoking cigarettes is not allowed
B10_2.
Vaping
might be less harmful to me than smoking cigarettes
B10_3.
I
like the flavors
B10_4.
Vaping
can help me quit or cut back on smoking cigarettes
B10_5.
Vaping helps me deal with cravings to smoke
B10_6.
A friend or family member suggested I vape as a way to quit
smoking
B10_7.
A friend or family member [IF
B9=3 insert:
shared/
IF B9=1 or 2 insert:
shares]
their
vaping device with me
B10_8.
Vaping is popular among people my age
B10_9.
I [IF
B9=3 insert:
was/
IF B9=1 or 2 insert:
am]
curious
about vaping
B10_10.
Other, specify
|
B11
|
Which
of those is the main reason you first tried/currently use
electronic vapor products?
|
[Show
list of responses provided in B10]
|
Deletion
|
N/A
|
N/A
|
B11a
|
You
indicated previously that you have tried electronic vapor products
before but do not currently use them every day or some days.
Please indicate the reasons why you do not use electronic vapor
products now
|
B11a_1.
I only use them temporarily when regular cigarettes are not
allowed or not wanted
B11a_2.
I have quit smoking both regular cigarettes and electronic vapor
products
B11a_3.
They are too expensive
B11a_4.
They do not satisfy my cravings
B11a_5.
They are not like real cigarettes (e.g., too heavy, do not feel
real)
B11a_6.
They taste bad
B11a_7.
I am concerned about the health effects of electronic vapor
products
B11a_8.
I was only curious about electronic vapor products when I tried
them
B11a_9.
They are inconvenient (e.g., difficult to charge, difficult to
refill)
B11a_10.
They are too strong
B11a_11.
Other, specify
|
Deletion
|
N/A
|
N/A
|
B11b
|
You
indicated previously that you currently smoke cigarettes and also
currently use electronic vapor products. Please indicate your
reasons for not switching completely from regular cigarettes to
electronic vapor products.
|
B11b_1.
I am still addicted to real cigarettes
B11b_2.
Electronic vapor products are too expensive
B11b_3.
I am still in the process of switching to vaping
B11b_4.
Electronic vapor products are not like real cigarettes (e.g., too
heavy, do not feel real)
B11b_5.
Electronic vapor products taste bad
B11b_6.
I am concerned about the health effects of electronic vapor
products
B11b_7.
Electronic vapor products are inconvenient (e.g., difficult to
charge, difficult to refill)
B11b_8.
My peers still use regular cigarettes
B11b_9.
I only use electronic vapor products temporarily when regular
cigarettes are not allowed or not wanted
B11b_10.
Other, specify
|
Deletion
|
N/A
|
N/A
|
B12
|
Do
you use electronic vapor products in places where smoking regular
cigarettes is not allowed?
|
1.
Yes
2.
No
|
Deletion
|
N/A
|
N/A
|
B12a
|
Do
you use electronic vapor products in any of the following places?
|
B12a_1.
Restaurants or bars
B12a_2.
Stores or shopping malls
B12a_3.
Airplanes
B12a_4.
Beaches, parks, or other outdoor places
B12a_5.
In your car or other type of vehicle
B12a_6.
In your home
B12a_7.
Somewhere else, specify
|
Deletion
|
N/A
|
N/A
|
B13
|
As
far as you know or believe is the use of electronic vapor products
in combination with regular cigarettes less harmful than smoking
only regular cigarettes, more harmful than smoking only regular
cigarettes, or equally as harmful as smoking only regular
cigarettes?
Please
indicate your answer on a scale of 1 to 5, where one is much less
harmful, 3 is the same as regular cigarettes, and 5 is much more
harmful.
|
1.Much
less harmful than smoking only regular cigarettes
2.
Slightly less harmful than smoking regular cigarettes
3.
Equally harmful as smoking only regular cigarettes
4.
Slightly more harmful than smoking regular cigarettes
5.
Much more harmful than smoking only regular cigarettes
|
Revision
|
In
your opinion, regularly vaping and smoking cigarettes is…
|
1.Much
less harmful to one’s health than only smoking cigarettes
2.
Slightly less harmful to one’s health than only smoking
cigarettes
3.
Equally harmful to one’s health as only smoking cigarettes
4.
Slightly more harmful to one’s health than only smoking
cigarettes
5.
Much more harmful to one’s health than only smoking
cigarettes
|
B14
|
Do
you want to quit using electronic vapor products for good?
|
1.Yes,
after I have successfully stopped smoking cigarettes
2.
Yes, but I will continue to smoke cigarettes
3.
No
|
Revision
|
Do
you want to quit vaping for good?
|
1.
Yes
2.
No
|
B15
|
Do
you plan to quit using electronic vapor products….
|
1.
In the next 7 days,
2.
In the next 30 days,
3.
In the next 6 months,
4.
In the next 1 year, or
5.
More than 1 year from now?
6.
I do not plan to quit using electronic vapor products for good
7.
Not sure/Uncertain
|
Deletion
|
N/A
|
N/A
|
D17
|
On
a scale from 1 to 5, with 1 begin the “lowest” and 5
being the “highest,” how would you rate quitting
smoking as a priority in your life?
|
1.
Lowest
2.
3.
4.
5.
Highest
|
Deletion
|
N/A
|
N/A
|
D22
|
How
likely do you think it is that smoking will worsen medical
complications from diabetes such as blindness, renal failure, or
amputations?
|
1.
Extremely likely
2.
Very likely
3.
Somewhat likely
4.
Very unlikely
5.
Extremely unlikely
|
Deletion
|
N/A
|
N/A
|
E7
|
Do
you think that breathing smoking from other people’s
cigarettes or from other tobacco products is…
|
1.
Not at all harmful to one’s health
2.
Somewhat harmful to one’s health
3.
Very harmful to one’s health
|
Deletion
|
N/A
|
N/A
|
E8a
|
How
likely is it that regularly breathing secondhand tobacco smoke
would cause nonsmokers to have asthma, infections, or lung damage?
|
1.
Extremely likely
2.
Very likely
3.
Somewhat likely
4.
Very unlikely
5.
Extremely unlikely
|
Revision
|
In
your opinion how likely is it that regularly breathing secondhand
tobacco smoke would worsen asthma or cause infections or lung
damage among nonsmokers?
|
1.
Extremely likely
2.
Very likely
3.
Somewhat likely
4.
Very unlikely
5.
Extremely unlikely
|
F4
|
What
type of Internet connection do you have for your home computer or
other primary computer?
|
1.Cable/DSL/Broadband/High-Speed
2.
Dial-Up
3.
Not Sure
|
Deletion
|
N/A
|
N/A
|
F18
|
Where
have you seen or heard about the TIPS campaign?
|
Across:
1.
Yes
2.
No
Down:
F18_1.
On TV
F18_2.
On the radio
F18_3.
In newspapers or magazines
F18_4.
On the Internet
F18_5.
Billboards or other outdoor ads
|
Deletion
|
N/A
|
N/A
|
F20
|
Sometimes
people use the Internet specifically for health-related reasons.
In the past 30 days, have you used the Internet for any of the
following reasons?
|
Across:
1.
Yes
2.
No
Down:
F20_1.
Looked for information about quitting smoking
F20_2.
Looked for information about electronic vapor products (e.g.,
e-cigarettes, e-vaporizers)
F20_3.
Looked
for information about nicotine replacement therapies (e.g.,
patches, gum, lozenges)
F20_4.
Downloaded
a mobile App to help you quit smoking
|
Revision
|
Sometimes
people use the Internet specifically for health-related reasons.
In the past 30 days, have you used the Internet for any of the
following reasons?
|
Across:
1.
Yes
2.
No
Down:
F20_1.
Looked for information about quitting smoking
F20_2.
Looked for information about vaping (using e-cigarettes or other
vaping products)
F20_3.
Looked
for information about nicotine replacement therapies (e.g.,
patches, gum, lozenges)
F20_4.
Downloaded
a mobile App to help you quit smoking
F20_5.
Signed up for a texting program to help you quit smoking
F20_6.
Created an online plan to help you quit smoking
|
F21
|
In
the past 30 days, have you shared information via email, social
media, blog or online forum/support group about any of the
following?
|
Across:
1.
Yes
2.
No
Down:
F21_1.
How to quit smoking
F21_2.
CDC Tips campaign messages/videos
F21_3.
Electronic
vapor products (e.g., e-cigarettes, e-vaporizers)
F21_4.
Nicotine replacement therapies (e.g., patches, gum, lozenges)
|
Deletion
|
N/A
|
N/A
|
F28_a
|
In
the past [FILL MONTHS SINCE CAMPAIGN LAUNCH] months, have these
ads stopped you from having a cigarette when you were about to
smoke one? Would you say…
|
1.
Never
2.
Once
3.
A few times
4.
Many times
|
Deletion
|
N/A
|
N/A
|
F28_x
|
Would
this ad make you want to quit smoking?
|
1.
Yes
2.
No
|
Deletion
|
N/A
|
N/A
|
F28_1x
|
On
a scale of 1 (not at all) to 5 (extremely), to what degree did the
ad focus on the benefits of quitting smoking cigarettes?
|
1.
Not at all
2.
Slightly
3.
Moderately
4.
Very
5.
Extremely
|
Deletion
|
N/A
|
N/A
|
F28_2x
|
On
a scale of 1 (not at all) to 5 (extremely), to what degree did the
ad focus on the consequences of continuing to smoke cigarettes?
|
1.
Not at all
2.
Slightly
3.
Moderately
4.
Very
5.
Extremely
|
Deletion
|
N/A
|
N/A
|
F28_3x
|
Please
rate the overall tone of the ad on a scale from 1 (extremely
negative) to 5 (extremely positive)
|
1.
Extremely negative
2.
Slightly negative
3.
Neither negative nor positive
4.
Slightly positive
5.
Extremely positive
|
Deletion
|
N/A
|
N/A
|
F30
|
For
the next few question think about all the advertisements you just
viewed and recalled seeing in the past 3 months.
Did
you talk to anyone about any of these ads?
|
1.
Yes
2.
No
|
Deletion
|
N/A
|
N/A
|
F31
|
When
you talked about the ads, did the person talking to you about the
ads encourage you to stop smoking?
|
1.
Yes
2.
No
|
Deletion
|
N/A
|
N/A
|
F31_x
|
Did
seeing these ads make you want to do any of the following?
|
1.
Quit smoking
2.
Cut back on the number of cigarettes I smoke
3.
Use electronic vapor products, such as e-cigarettes, vape-pens,
hookah-pens, electronic hookahs (e-hookahs), electronic cigars
(e-cigars), electronic pipes (e-pipes), or e-vaporizers
4.
Switch to mild or some other brand of cigarettes
5.
Use nicotine replacements like the nicotine patch, nicotine gum,
nicotine lozenges, nicotine nasal spray, or nicotine inhaler
6.
Use medications like Wellbutrin, Zyban, buproprion, Chantix, or
varenicline
7.
Call a telephone quitline
8.
Visit a web site such as Smokefree.gov or CDC.gov/Tips
9.
Talk to a doctor or other health professional about quitting
|
Deletion
|
N/A
|
N/A
|
F37
|
Where
did you see these advertisements?
|
Across:
1.Yes
2.No
Down:
F37_1.
Magazines
or print
publications
F37_2.
Websites
online
F37_3.
Public
places such as bus
shelters,
bus
interiors,
outdoor bulletins, etc.
|
Revision
|
Where
did you see these advertisements?
|
F37_1.
Magazines
or print
publications
F37_2.
Websites
online
|
F37a
|
N/A
|
N/A
|
Addition
|
In
the past XX Months, since [DATE], have you seen any of these ads
in public places outside your home such as billboards, bus
shelters, or bus interiors?
|
1.
Yes
2.
No
|
F38
|
When
you go to a convenience store, supermarket, or gas station, how
often do you see ads or promotions for electronic cigarettes or
e-cigarettes?
|
1.
I never go to a convenience store, supermarket, or gas station
2.
Never
3.
Rarely
4.
Sometimes
5.
Most of the time
6.
Always
|
Revision
|
When
you go to a convenience store, supermarket, or gas station, how
often do you see ads or promotions for vaping products?
|
1.
I never go to a convenience store, supermarket, or gas station
2.
Never
3.
Rarely
4.
Sometimes
5.
Most of the time
6.
Always
|
G1
|
How
many children aged 17 or younger live in your household 6 months
or more of the year?
|
_______Number
of children
|
Revision
|
How
many people are 17 years of age or younger and currently live in
your household at least 50% of the time? If none, enter “0.”
Include babies and small children. Your answer will help represent
the entire U.S. population and will be kept confidential. Thank
you!
|
________Number
of children
|
G6
|
The
next question is about the total
income of
YOUR HOUSEHOLD for the PAST 12 MONTHS. Please include your income
PLUS the income of all members living in your household (including
cohabiting partners and armed forces members living at home).
Please count income BEFORE TAXES and from all sources (such as
wages, salaries, tips, net income from a business, interest,
dividends, child support, alimony, and Social Security, public
assistance, pensions, or retirement benefits).
Was
your total HOUSEHOLD income in the past 12 months…
|
1.
Below $35,000
2.
$35,000 or more
3.
Don’t Know
|
Revision
|
How
much is the combined income of all members of YOUR HOUSEHOLD for
the PAST 12 MONTHS? Please
include your income PLUS the income of all members living in your
household (including cohabiting partners and armed forces members
living at home). Please count income BEFORE TAXES and from all
sources (such as wages, salaries, tips, net income from a
business, interest, dividends, child support, alimony, and Social
Security, public assistance, pensions, or retirement benefits).
|
1.
Below $50,000
2.
$50,000 or more
3.
Don’t Know
|
G6a
|
We
would like to get a better estimate of your total HOUSEHOLD income
in the past 12 months before taxes. Was it…
|
1.Less
than $5,000
2.
$5,000 to $7,499
3.
$7,500 to $9,999
4.
$10,000 to $12,499
5.
$12,500 to $14,999
6.
$15,000 to $19,999
7.
$20,000 to $24,999
8.
$25,000 to $29,999
9.
$30,000 to
$34,999
|
Revision
|
We
would like to get a better estimate of your total HOUSEHOLD income
in the past 12 months before taxes. Was it…
|
1.Less
than $5,000
2.
$5,000 to $7,499
3.
$7,500 to $9,999
4.
$10,000 to $12,499
5.
$12,500 to $14,999
6.
$15,000 to $19,999
7.
$20,000 to $24,999
8.
$25,000 to $29,999
9.
$30,000 to
$34,999
10.
$35,000 to $39,999
11.
40,000 to $49,999
|
G6b
|
We
would like to get a better estimate of your total HOUSEHOLD income
in the past 12 months before taxes. Was it…
|
1.
$35,000 to
$39,999
2.
$40,000 to
$49,999
3.
$50,000 to
$59,999
4.
$60,000 to
$74,999
5.
$75,000 to
$84,999
6.
$85,000 to
$99,999
7.
$100,000 to
$124,999
8.
$125,000 to
$149,999
9.
$150,000 to
$174,999
10.
$175,000 or more
|
Revision
|
We
would like to get a better estimate of your total HOUSEHOLD income
in the past 12 months before taxes. Was it…
|
1.
$50,000 to
$59,999
2.
$60,000 to
$74,999
3.
$75,000 to
$84,999
6.
$85,000 to
$99,999
4.
$100,000 to
$124,999
5.
$125,000 to
$149,999
6.
$150,000 to
$174,999
10.
$175,000 to $199,999
11.
$200,000 to $249,999
12.
$250,000 or more
|
G7
|
Are
you now married, widowed, divorced, separated, never married, or
living with a partner?
|
1.Married
2.
Widowed
3.
Divorced
4.
Separated
5.
Never married
6.
Living with a partner
|
Revision
|
Are
you now…
|
1.
Married
2.
Widowed
3.
Divorced
4.
Separated
5.
Never married
|
G7a
|
N/A
|
N/A
|
Addition
|
Are
you currently living with a partner to whom you are not married?
|
1.Yes
2.
No
|
ADD1
|
Those
are all of our questions. Thanks so much for your participation in
our survey. As a token of our appreciation, we would like to send
you [IF SAMPLE
=
KP WITHDRAWN, “$15”; IF SAMPLE=ABS, “$20”].
Would you please
provide
your name and mailing address so that we can put the check in the
mail. This information will not be connected with your survey
responses in any way.
After
you have entered your information, please make sure to click
“Next.”
|
Name
(First/Last):
Street
Address (If applicable, include unit number):
City:
State:
Zip
Code:
|
Revision
|
Those
are all of our questions. Thanks so much for your
participation in our survey. As a token of our appreciation,
we would like to send you $[IF SAMPLE = KP WITHDRAWN, $15; IF
SAMPLE=ABS, INSERT INCENTIVE VALUE FROM LOOKUP TABLE based on MNO;
IF SAMPLE=ABS and incentive value is missing from lookup table,
insert: $20].
Please
verify your name and mailing address so that we can put the check
in the mail. To ensure that you will be able to deposit or
cash the check, please be sure to provide us with your full first
AND last name; if you provide incomplete or inaccurate
information, you may not be able to deposit the check. This
information will not be connected with your survey responses in
any way.
Please
select the field(s) that you’d like to update. If all of the
information is correct, please select “All of the above are
correct”.
|
1.Name
(First/Last):
2.Mailing
Address:
3.All
of the above are correct
|
ADD1_1
|
N/A
|
N/A
|
Addition
|
Please
type in the name to whom you’d like us to send the incentive
check:
|
Name___________
|
ADD1_2
|
N/A
|
N/A
|
Addition
|
Please
type in the address to where we should send the incentive check:
|
Street
Address:
City:
State:
Zip
Code:
|
ADD2
|
N/A
|
N/A
|
Addition
|
Is
the contact information below now up-to-date?
|
1.
Yes
2.
No
|
CONTACT_A
|
N/A
|
N/A
|
Addition
|
Thank
you for your participation in this important study! If you entered
your address information on the previous question, your check for
participation will arrive in the next 4 – 6 weeks.
The
CDC will also
have the opportunity to do at least one more survey in the future,
with additional rewards and prizes for
participation.
Would you be willing to participate in another survey for the
CDC?
|
1.
Yes
2.
No
|
CONTACT_A1
|
N/A
|
N/A
|
Addition
|
Is
this the address where you would like us to send your next CDC
survey invitation?
|
1.
Yes
2.
No
|
CONTACT_A2
|
N/A
|
N/A
|
Addition
|
Please
provide us with the address that you would like us to use to send
you your next CDC survey invitation
|
Street
Address:
City:
State:
Zip
Code:
|
CONTACT_B
|
N/A
|
N/A
|
Addition
|
So
that you can participate in the future if you choose to do so,
please provide your e-mail address and best phone number to reach
you below. Remember, you can decline to do any survey at that
time if you do not want to do it.
|
My
email address is:
The
best phone number to reach me:
|
CONTACT2_A
|
N/A
|
N/A
|
Addition
|
In
case we are unable to reach you through the email address or phone
number you provided in the previous question, is there an
alternate email address or a phone number to be able to reach?
It
is very important for us to hear back from you for future surveys
that we will be sending out so we can ensure that the researchers
have complete data for this new and important study.
|
Alternate
Email:
Alternate
phone number to reach you:
|